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if
Hi
HARRY R- ABBOTT
MEMOTIIAD
LIIW^TOT
Jnis volume presentee) by
-^dL^
%J:
Digitized by the Internet Archive
in 2011 with funding from
University of Toronto
http://www.archive.org/details/principlespractOOosle
This is a rare edition,
I
because a few of the first
edition were issued before
the Tii stake in the spelling
of "Gorgas" was noticed.
The "e" vjas corrected in
folio ^Ying copies. / J .
1
Tlll^: l'IJI\(Il'LJ^:S AXD
ri^iACJTICE OF ^nCDICIXE
DKSKiNKI) FOR 'I^IIH USE oF
IMJACrriTIONEKS AM) STUDENTS OF MEDICINE
BY
WILLIAM OSLER, M. D.
FKT.I.OW OF THE HOYAL COLLEGE OF PFIYSICIAXS, LOXDOV
rUOFKSSOU OF MEDUnXE IX THE JOHNS HOPKINS INIVERSITY AND
rHYSU"IAN-I\-('HIEF TO THE JOHNS HOPKINS HOSPITAL, I5ALTIMOKE
FOKMERLY PKOFESSOIi OF THE INSTITUTES OF MEDICINE, MC GILL UNIVERSITY, MONTREAL
AND PROFESSOR OF CLINICAL MEDICINE
IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA
NEW YORK
D. APPLETON AND COiMPAXY
1892
Copyright, 1892,
By D. APPLETON AND COMPANY.
TO
THK MEMORY OF MY TEACHERS:
wii.iJAM Airnirii joiinsox,
PRIEST OF TllK I'AKISII OF WESTON, ONTARIO.
-TAJIKS BOVKLL,
OF Tin: TORONTO sniooii of medicine,
AND OF THE
UNIVERSITY OF TRINITY COLLEGE, TORONTO.
ROBERT PAL:\IER HOWARD,
DEAN OF THE MEDICAL FACULTY AND PROFESSOR OF MEDICINE,
M^GILL UNIVERSITY, MONTREAL.
K ( ) T I : .
IVfy tlijuiks iii'c due lo my fni-iiicr first assistant, II. A. Litlcur
for nuicli licl]), (linH't and indirect; to iiis suecesKor, W. S. Tliaycr,
for assistance in the section on iJlood Diseases and for the
pre[)aration of the illustrative charts; to 1). Meredith KeeftC, for
the statistics on tuberculosis; to II. M. Thomas, for many 8iii^-
gestions in the section on Nervous Diseases, and particularly in
the section on Topical Diagnosis; to L. P. Powell, of the J(jhns
Hopkins Fniversity Library, for a careful revision of the manu-
script; and to INTiss P. (). llunipton, for valuable aid, especially in
the preparation of the index.
Johns Hopkins Hospital,
Baltimore, January i, 1S92.
"Experience is fallacious and judgment difficult."
Hippocrates : Aphorisms, I.
"And I said of medicine, that this is an art which
considers the constitution of the patient, and has
principles of action and reasons in each case,"
Plato : Oeorgias.
COiN 'V !•: N 'l^s.
SKCTION I.
Sl'KCiriC IM'IKTlorS DISKASKS
1. Typhoid Vvxcv .
II. 'ry[)lius FoviT
HI. Kolapsinjj Fevi>i*
IV. Small-pox
Variola Voi'a
llaMnorrliai^ic Small-])ox
Varioloid .
V. Vaccinia (Cow-jiox) — Vaccination
VI. Varicella (Chicken-pox
VII. Scarlet Fever
VIII. J\Ieasles .
IX. Kubella (Kotheln) .
X. Epidemic Parotitis (Mumps)
XI. Whooping-cough .
XII. Influenza
XIIT. Dengue ....
XIV. Cerebro-spinal Meningitis
XV. Diphtheria .
XVI. Eryeipelas .
XVII. Septicaemia and Pya^nia
SepticaMuia
Pyaemia
XVIII. Choiera Asiatica .
XIX. Yellow Fever
XX. Dysentery
XXI. Malarial Fever .
Intermittent Fever .
Continued and Remittent Malarial
Pernicious Malarial Fever
Malarial Cachexia
XXII. Anthrax
XXIII. Rabies .
XXIV. Tetanus
XXV. Syphilis.
Acquired .
Congenital
Visceral
Fever
PAnE
1
'.id
43
4«
49
52
.•54
r,o
(;.")
07
77
81
82
84
87
90
92
09
110
114
114
116
lis
125
130
140
147
151
152
153
156
159
162
165
107
109
172
Vlll
CONTENTS.
XX y I. Tuberculosis
1. General Etiology and Morbid Anatomy .
2. Acute Tuberculosis
3. Tuberculosis of the Lymph-glands (Scrofula)
4. Pulmonary Tuberculosis (Phthisis, Consumption)
5. Tuberculosis of the Serous Membranes
G. Tuberculosis of the Alimentary Canal
7. Tuberculosis of the Liver ....
8. Tuberculosis of the Brain and Spinal Cord
9. Tuberculosis of the Genito-urinary System
10. Tuberculosis of the Arteries
11. Prognosis in Tuberculosis .
12. Prophylaxis in Tuberculosis
13. Treatment of Tuberculosis .
XXVn. Leprosy
XXVIII. Glanders
XXIX. Actinomycosis
XXX. Infectious Diseases of Doubtful Nature
1. Febricula (Ephemeral Fever)
2. Weil's Disease .
3. Milk-sickness
4. Malta Fever
5. Mountain Fever
6. Miliary Fever (Sweating Sickness)
PAGE
184
184
197
204
208
235
239
242
242
243
246
246
247
249
256
259
2G1
2G4
264
2G5
266
266
268
268
SECTION n.
CONSTITUTIONAL DISEASES.
I. Rheumatic Fever 270
II. Chronic Rheumatism 278
III. Pseudo-rheumatic Affections 279
IV. Muscular Rheumatism , . , . . 281
V. Arthritis Deformans (Rheumatoid Arthritis) 283
VI. Gout 287
VII. Diabetes Mellitus 295
VIII. Diabetes Insipidus . . . . , 305
IX. Rickets 307
X. Scurvy (Scorbutus) 313
XI. Purpura 316
XII. IIa3mophilia 320
SECTION III.
DISEASES OF THE DIGESTIVE SYSTEM.
Diseases of the Mouth 323
Stomatitis 323
Aphthous Stomatitis 323
Ulcerative Stomatitis 324
Parasitic Stomatitis (Thrush) 325
Gangrenous Stomatitis 326
Mercurial Stomatitis 337
ciiNTKNTS.
is
II. Diseases of llir Siiliviirv (iIiukIh
ll\ |»(>r<('crrl ion . . , ..
XrroMloiiiiii .....
Inlliiiiiiiml ii)ii of tlii^ Siiliviit'V (ilatnls
III. I )isrHS('S of llir IMllirvilX .
('iiciilalury I >isl iirliiiiicfs
Aciilo l'liiirvii;;it is ....
Clii-oiiic IMiiirvii^Mtis
IMccinl i«'ii of I ho IMmryiix
Aculf Infi'cliouH IMih'^'iiion of llic rimiyn.x
lu'lro-i»liarvti^('iil Abscess
Aii^iiiJi liudovici ....
IV. I)iseiis(>s of t ho Tonsils
l<\)lliciiliir or Ijaeimar 'roiisillitis
Siippiirativo 'ronsillilis .
(Miroiiie Tonsillitis
V. Diseases of the (I'jsopha^us
AfUlo (Ksophaj^itis
Spasm of (he (l']sopha^us
Stricture of the (Ksophji^us .
Cancer of the (Kscphai^us
Iviipture of the (Ksophau^us .
Dilatatiotis and Diverticula .
VI. Diseases of the Stomach .
Methods of IMinical Examination .
Acute Gastritis ....
Phle!:!:monous Gastritis
Toxic (lastritis ....
Diphtheritic Gastritis
Mycotic Gastritis
Chronic Gastritis (Chronic Dyspepsia)
Neuroses of Stomach
Gastralgia
Nervous Dyspepsia
Nervous Vomiting
Peristaltic Unrest
Rumination ....
Dilatation of Stomach .
Peptic Ulcer (Gastric and Duodenal)
Cancer of Stomach.
TTicmorrhage from the Stomach .
VII. Diseases of the Intestines .
1. Diseases of the Intestines associated with
Catarrhal Enteritis
Diarrhoea ....
Enteritis in Children .
Diphtheritic or Croupous Enteritis
Phlegmonous Enteritis
Mucous Colitis
Ulcerative Enteritis
2. Miscellaneous Affections of the Bowels
3. Appendicitis (Typhlitis and Perityphliti
Diarrhoea
VAum
;:;;(>
:m
Mil
:{;:2
:m
:v.\2
'Mir)
'S.'M
:{:59
:{40
:{41
.">42
;{4:J
344
.U4
344
348
350
350
351
351
351
359
359
3G0
361
3G3
362
364
368
376
385
388
388
388
388
391
395
396
396
397
403
405
X CONTENTS.
PAGE
Typhlitis 405
A})pen(licitis 406
4. Intestinal Obstruction , . 413
5. Constipation (Costiveness) 420
VIII. Diseases of the Liver 423
1. Jaundice (Icterus) 423
2. Affections of the Blood-vessels of the Liver 427
3. Diseases of the Bile-passages 430
Catarrhal Jaundice 430
Cholelithiasis (Gall-stones) 431
Other Affections of the Bile-ducts 437
4. Cirrhosis 440
5. Abscess of the Liver . 446
6. New Growths in the Liver . 451
7. Fatty Liver 455
8. Amyloid Liver 456
IX. Diseases of the Pancreas 457
1. Hfemorrhage 457
2. Acute Pancreatitis 458
3. Chronic Pancreatitis 4G0
4. Pancreatic Cysts 460
5. Cancer 401
X. Diseases of the Peritonaeum 4G2
1. Acute General Peritonitis 462
2. Peritonitis in Infants , . 4G6
3. Localized Peritonitis 466
4. Chronic Peritonitis 467
5. New Growths in the Peritonajura 468
6. Ascites (Hydro-peritonaeum) 469
SECTION IV.
DISEASES OF THE RESPIRATORY SYSTEM.
I. Diseases of the Nose
Acute Coryza
Chronic Nasal Catarrh
Autumnal Catarrh (Hay Fever)
E[)istaxis ....
II. Diseases of the Larynx .
1. Acute Catarrhal Laryngitis .
2. Chronic Laryngitis .
3. (Edematous Laryngitis .
4. Membranous Laryngitis (Croup)
5. Spasmodic Lary^ngitis (Laryngismus Str
6. Tuberculous Laryngitis .
7. Syphilitic Laryngitis
HI. Diseases of the Bronchi .
1. Acute Bronchitis .
2. Chronic Bronchitis .
3. Bronchiectasis.
4. Bronchial Asthma .
5. Fibrinous Bronchitis
idulus)
474
474
475
477
478
480
480
481
481
482
486
487
489
400
490
402
405
407
501
CONTMNTS.
XI
liitis)
I\'. Dist'H^t'S of llir Iiim^«»
1. ('in'iilalnry hi-'MirliMiiri-s in \\n- Lnn
2. I'llrlllllnllitl .....
«t. ( 'lii'oiiir IiiliT^t II ml riD'iiiiioiiia i< III
•t. hi-(>iiclii)-|in<'iiiii<iiijii (( 'jipill'Mv I'roin
5. Km|iliys('mii
( 'iHiipcii.Nnlorv Miiipliv.'^riiKi
lly|MTl I'opliic l'!ii)|)liyM'iiiii
Alro|)|ii(' i'linpliysciMii
ft. (lunun'iii' (»r 1Im> liiiii;,'
7. Abscess of tlu^ lillli;; .
8. IMuMimoiiokoniosis
1). Ni'w (iiowtlis ill the l,iiiij;s
V. Discasps of tlu« IMi'urn
1. Aciito IMtMirisy .
Fibrinous or IMaslic IMcurisy
SiTo-llhriiious IMourisy .
INiruliMit IMcurisy (KnipytMiia
Tulicrculous IMcuri.sy
Oilier N'ariclics of Pleurisy
2. (Mironic IMciu'isy
'S. Hydro! liorax
4. Piunuuot liorax (ily(lro-|)ncuniotliorax and Pyo
Affect ions of the jMediiistiiiuin
pneumothorax
rAOK
rm
MI
.'( ; ' ' '
:.i I
Till
51(1
r,r,<)
r,:,2
r,:,:i
nrid
r)r,H
rtrtH
558
558
r,i',r,
r,7i
'ill
574
577
SP]CTIOX V.
DISEASES OF THE CIRCULATORY SYSTEM.
I. Diseases of the Pericardium
1. Pericarditis ....
2. Other AlTections of the Pericardium
II. Diseases of the Heart .
1. Endocarditis
Acute Endocarditis
Chronic Endocarditis
2. Chronic Valvular Disease .
Aortic Incompetency
Aortic Stenosis
IMitral Incompetency
I\Iitral Stenosis
Tricuspid Valve Disease .
Pulmonary Valve Disease
Combined Valvular Lesions
3. Hypertrophy and Dilatation
Hypertrophy of the Heart
Dilatation of the Heart .
4. Affections of the ^Myocardium
Aneurism of the Heart .
Rupture of the Heart
Xew Growths and Parasites
Wounds and Foreign Bodies
5M1
5!J1
502
592
592
599
G02
G02
608
GIO
014
G18
G20
G20
G28
628
6:^5
640
646
647
647
648
xii CONTENTS.
PAGE
6. Neuroses of the Heart 649
Palpitation 649
Arrhythmia 650
Rapid Heart (Tachycardia) 652
Slow Heart (Bradycardia) 653
Angina Pectoris 655
6. Congenital Affections of the Heart 659
HI. Diseases of the Arteries 663
1. Degenerations 663
2. Arterio-sclerosis (Arterio-capillary Fibrosis) 664
3. Aneurism 670
Aneurism of the Thoracic Aorta 671
Aneurism of the Abdominal Aorta 680
Aneurism of the Branches of the Abdominal Aorta .... 681
Arterio-venous Aneurism 682
Consrenital Aneurism 682
SECTION VI.
DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
I. Anaemia 684
Secondary Anaemia 684
Primary or Essential Anaemia 686
II. Leukaemia 696
III. Hodgkin's Disease 704
IV. Addison's Disease 708
V. Diseases of the Thyroid Gland 711
Goitre 711
Tumors of the Thyroid . 712
Exophthalmic Goitre 712
Myxoedema , . 714
SECTION vn.
DISEASES OF THE KIDNEYS.
I. Anomalies in Form and Position o .717
Movable Kidney . .717
II. Circulatory Disturbances o . 721
III. Anomalies of the Urinary Secretion 722
1. I hematuria 722
2. Ilaemoglobiiiuria , . 723
3. Albuminuria . 725
4. Pyuria (Pus in the Urine) 729
5. Chyluria (Non-parasitic) 730
6. Lithuria 730
7. Oxaluria 733
8. Cystinuria 734
9. Phosphaturia 734
10. Indicanuria 735
11. Melanuria 736
12. Other Substances 736
CONTKNTS.
Xlil
IV.
V.
VI.
\ II.
VIM.
1\.
X.
XL
XII.
Xlll.
rnnniH
A<Mlll< hli^jlll'N I)iH«'HMO
Cliroiiir Ilii^'lil'.M DihcuHc .
Clirnliic I'lUflirh) limlnlis NrplintM
Cliroiuc liilrr.stiliiil NrpliritiH
A my l( •ill hiscaso ....
ry.-iitis
II y(ln>in'|i|ir<»>is ....
Nt'plintlilhia^is (Kciml Calculu.s)
Tumors of tlu' Kitlncy
(\v.sti(^ I>i.s(Mi.s(> of tlir Kidney .
IViincphrii! AbMivs.s
VAUU
7:{7
:\\
740
717
liU
7:.H
7^:2
n\r,
7;o
7:2
ir.i
SECTION VIII.
DISEASES OF THE NEKVOUS SYSTEM.
1. nisca.^^t'.^ of llu^ NiTvcs ....
1. Nouiitjjs (Inflammation of the Nerve-filjivs)
2. NiMiromata
3. Disoaso.s of till' Cranial N'crvo.s
Olfactory Nrrvc ....
Optic Nerve and Tract
Lesions of the lietina
Lesions of the Optic Nerve
AlTections of the Chiasma and Tract
AtTections of the Tract and Centres
Motor Nerves of tiie Eyeball
Fifth Nerve
Facial Nerve ....
Auditory Nerve ....
Glosso-pharyngeal Nerve
Pneumogastric Nerve .
Spinal Accessory Nerve
llypoiilossal Nerve
4. Diseases of the Spinal Nerves
Cervical Plexus ....
Brachial Plexus ....
Lumbar and Sacral Plexuses
Sciatica
n. Diseases of the Spinal Cord
1. Affections of the Mening:es
Diseases of the Dura Mater .
Diseases of the Pia Mater .
Ihemorrhaije into the Spinal Membranes
2. Affections of the Blood-vessels
3. Acute Affections of the Spinal Cord
Acute Diffuse Myelitis
Myelitis of the Anterior Horns .
Acute and Subacute Polio-myelitis in Adults
Acute Ascending (Landry's) Paralysis
4. Chronic Affections of the Spinal Cord ,
Spastic Paraplegia ....
I'i'}
7M
7H2
7H2
IK]
>(>
7H7
7^8
700
TU.i
707
bOl
805
805
8(19
812
813
813
814
817
818
8-iO
^20
820
822
824
825
828
828
831
8^!5
835
836
836
xiv CONTENTS.
PAGE
Locomotor Ataxia 840
Hereditary Ataxia (Friedreich's Ataxia) 848
Syringo-inyelia 849
Compression of the Spinal Cord 851
Lesions of the Cauda Itlquina and Conus Medullaris .... 854
Tumors of Spinal Cord and its Membranes 855
Progressive (Spinal) Muscular Atrophy 857
Bulbar Paralysis 860
in. Diseases of the Brain 862
1. Affections of the Meninges 862
Diseases of the Dura Mater (Pachymeningitis) 862
Diseases of the Pia Mater 863
2. Affections of the Blood-vessels 867
Hypera?mia 867
Anaemia 868
QCdema of the Brain 869
Cerebral Haemorrhage 870
Embolism and Thrombosis (Cerebral Softening) 878
Aneurism of the Cerebral Arteries 883
Endarteritis 884
Thrombosis of the Cerebral Sinuses and Veins 885
3. Affections of the Substance 887
Topical Diagnosis 887
Aphasia 898
Inflammation of the Brain 903
4. Hemiplegia and Diplegia in Children 906
Hemiplegia 906
Spastic Diplegia (Birth Palsies) 909
Spastic Paraplegia 910
5. Sclerosis of the Brain 911
Miliary Sclerosis 912
Diffuse Sclerosis 912
Tuberous Sclerosis 913
Insular Sclerosis (Sclerose en Plaques) 913
6. Chronic Diffuse Meningo-encephalitis 914
7. Tumors of the Brain 918
8. Chronic Hydroce})halus 922
IV. General and Functional Diseases 924
1. Acute Delirium (Bell's Mania) 924
2. Paralysis Agitans 926
Other Forms of Tremor 929
3. Acute Chorea (Sydenham's Chorea ; St. Vitus's Dance) .... 929
4. Other Affections described as Chorea 942
Chorea Major; Pandemic Chorea 942
Habit Spasm; Convulsive Tic 942
Saltatoric Spasm 943
Chronic Chorea 944
Rhythmic Chorea 945
5. Infantile Convulsions (Eclampsia) 945
6. Epilepsy 948
Gnnid Mai 950
Petit Mai 053
\
CONTENTS.
XT
rAOB
.Fiirkmniijiu Kpilj'psy . 053
7.
Mi^'iiiiiic . . . 057
H.
Nriinil^'iii O.'JO
0.
Pr«)f«'H.si«)iml SpuHmH; ()c(UipHti<»n NouroM-^ . IHJJI
10.
'r«'(auv .....
WVi
11.
liyslcriu
. 0«7
(^»nvul.^iv^ l<\)iin
.
068
Non-coiivulsiv«i l''itrm .
000
12.
NtMini.sthcniH ....
078
IM.
Tiu' 'rnimiialio NiMiroscs.
081
11.
OtluT l'\>rms ol l''uMcli<»iial I'araly
sis
unr,
IVriodii'al i'aralvsis .
1»M.',
A.stasia — Abasia .
UHC,
V. Vjvso-inolor and 'i'nipliic DKs{)r(U'i*s
UH7
1.
Ixayiuiud's Disease .
UH7
2.
Antjii)-neurotic (Kdetna .
OHO
8.
Facial lleini-atrophy
900
4.
Acromegalia ....
im
5.
St'l(>r(idenna ....
Ainhum ....
^
mi
004
SECTION IX.
DISEASES OF THE MUSCLES.
I. Myositis OO.5
II. Idiopathic Muscular Atropliy . . . .
1. Psoudo-hypertrophic Muscular Atrophy
2. Prinuiry Atrophic Muscular Paralysis .
III. Thomsen's Disease ; Myotonia Congenita
IV. Paramyoclonus Multiplex .....
006
900
907
008
999
SECTION X.
THE INTOXICATIONS; SUN-STROKE; OBESITY.
I. Alcoholism 1001
1. Acute Alcoholism , . 1001
2. Chronic Alcoholism 1001
3. Delirium Tremens 1003
II. Morphia Habit . 1005
III. Lead Poisoning , . 1007
IV. Arsenical Poisoning 1011
V. Ptomaine Poisoning 1012
1. Meat Poisoning 1013
2. Poisoning by Milk Products . lOU
3. Poisoning by Shell-fish and Fish 1014
VI. Grain Poisoning lOlo
1. Ergotism . 1015
2. Lathyrism 1016
3. Pellagra 1016
VII. Sun-stroke 1017
VIII. Obesity 1019
B
xvi CONTENTS.
SECTION XI.
DISEASES DUE TO ANIMAL PARASITES.
PAGE
I. Psorospermiasis 1023
1. Internal Psorospermiasis 1022
2. Cutaneous Psorospermiasis 1023
II. Distomiasis 1024
III. Diseases caused by Nematodes 1025
1. Ascariasis 1025
2. Trichiniasis ' . . 1026
3. Ankylostomiasis 1031
4. Filiariasis 1032
5. Dracontiasis «... 1034
6. Other Nematodes 1035
IV. Diseases caused by Cestodes 1036
1. Intestinal Cestodes : Tape-worms 1036
2. Visceral Cestodes „ . .1039
Cysticercus Cellulosee 1039
Echinococcus Disease 1041
Multilocular Echinococcus 1046
V. Parasitic Arachnida . . . 1047
VI. Parasitic Insects 1048
VII. Pseudo-parasites (Myiasis) 1050
UJIAUTS AA'l) II.I.USTJiA'nONR
CIIAIIT
1. 'rv|»li(>i(l I'\v('r will) Ivclnpsc*
II. Tvplioid Im-vct— II yprrpN ifxiii — Dciith
III. lllustnitin;; (ho lUotnl C-lmn;;i\s in TvpliDJd I'Vvt
I\'. Tvpiioiil l'\»vi>r — IIa'in()rrlm«;(! from the Bowels
V. lUu.stnitiii^' Inllut'iico of Baths in Typlioid Fovi>
VI. Rolnpsiiii^ Fovor (aftor Murchison)
\'II. Small-pox (after Strl\nipcll) .
VIII. llaMnorrha^ii' Smull-itox ....
IX. Scarlet Fover (after Striimpell)
X. Measles (after Striimpell) ....
XI. Malaria — Tertian Ague ....
XII. Illustrating Heredity in Tuberculosis.
XIII. Chronic Tuberculosis, Two-hourly Chart for Three Days
XIV. Blood Chart, illustrating Rapid Production of Ana'mia in
ILrmorrhagica
XV. Temperature, Pulse, and Respiration Chart in Pneumonia
XVI. Blood Chart, illustrating AnaMnia in Purpura Ihrmorrhagica
XVII. Blood Chart, illustrating Chlorosis
XVIII. Blood Chart, illustrating Pernicious Ana^nia
XIX. Blood Chart, illustrating Leukaemia
f*AOB
12
M
18
21
35
50
53
. 70
. '78
148 and 149
. 188
. 224
Purpura
319
518
G85
693
701
I. Optic and Visual Tracts (after Starr) 788
II. Motor Area of the Cerebral Cortex (after Mills) 890
III. Motor Tract (after Starr) 892
IV. Degeneration of Pyramidal Tract in Hemisphere, Crus, Pons, and Me-
dulla (after Gowers) 893
V. Lichtheim's Schema in Aphasia 899
* The red shows the two-hourly, the black the morning and evening temperature.
THE riiACTiCK UK MEDKMMv
SKCTION I.
SPECIFIC INFECTIOUS DISKASKS.
I. TYPHOID FEVER.
Definition. — An infectious disease, characterized anatomically by
liyperphisiii ami ulceration of the lymph-follicles of the intestines, swell-
ing of the mesenteric glands and spleen, and parenchymatous changes
in the other organs. The bacillus of Eberth is constantly present in the
lesions. Clinically the disease is marked by fever, a rose-colored eruption,
diarrhoea, abdominal tenderness, tympanites, and enlargement of the
spleen ; but these symptoms are extremely inconstant, and even the fever
varies in its characters.
Historical Note. — The dates 1813 and 1850 include the modern
discussion of the subject. Prior to the former year many observers had
noted clinical differences in the continued fevers. Huxham in particular,
in his remarkable essay, had recognized varieties. In 1813 Pierre Breton-
neau, of Tours, distinguished "dothienenterite " as a separate disease; and
Petit and Serres described entero-mesenteric fever. Trousseau and Vel-
peau, students of Bretonneau, were, in 1820, instrumental in making his
views known to Andral and others in Paris. In 1829 Louis' great work
appeared, in which the name " typhoid " was given to the fever. At this
period typhoid fever alone prevailed in Paris, and it was universally be-
lieved to be identical with the continued fever of Great Britain, where
in reality typhoid and typhus coexisted, and the intestinal lesion was
regarded as an accidental occurrence in the course of ordinary typhus.
Louis' students returning to their homes in different countries had
opportunities of studying the prevalent fevers in the thorough and sys-
tematic manner of their master. Among these -were certain young
American physicians, to one of whom, Gerhard, of Philadelphia, is due
the great honor of having first clearly laid down the differences between
the two diseases. His papers in the American Journal of the Medical
Sciences are undoubtedly the first in any language which give a full and
2
2 SPECIFIC INFECTIOUS DISEASES.
satisfactory account of the clinical and anatomical distinctions we now
recognize. No student should fail to read these articles, among the most
classical in American medical literature.
Louis' influence was early felt in Boston, to which, in 1833, James
Jackson, Jr., had returned from Paris. In this year he demonstrated, in
his father's wards at the Massachusetts General Hospital, the identity of
the typhus of this country with the typhoid of Louis. He had already,
in 1830, noticed the intestinal lesions in the common fever of New Eng-
land. Though cut off at the very outset of his career, we may reason-
ably attribute to his inspiration the two elaborate memoirs on typhoid
fever which, in 1838 and 1839, were issued from the Massachusetts Gen-
eral Hospital, by James Jackson, Sr., and Enoch Hale. These, with Ger-
hard's articles, contributed to make t3^phoid fever, as distinguished from
typhus, widely recognized in the profession here long before the distinc-
tions were recognized generally in Europe. Thus, the diseases were de-
scribed under different headings in the first edition of Bartlett's admirable
work on Fevers published in 1842.
The recognition in Paris of a fever distinct from typhoid, without in-
testinal lesions, was due largely to the influence of the able papers of
George C. Shattuck, of Boston, and Alfred Stille, of Philadelphia, which
were read before the Societe medicale d'Observation in 1838. At Louis'
request, Shattuck went to the London Fever Hospital to study the disease
in England, where he saw the two distinct affections, and brought back a
report which was very convincing to the members of the society.
Stille had the advantage of going to Paris knowing thoroughly the
clinical features of typhus fever, for he had been Gerhard's house-physician
at the Philadelphia Hospital, where he had studied during the epidemic
of 1836. At La Pitie, with Louis, he saw quite a different affection, while
in London, Dublin, and Naples he recognized typhus as he had seen it in
Philadelphia. The results of his observation were given in an exhaust-
ive paper which presented in tabular form the contrasts and distinctions,
clinical and anatomical, which we now recognize.
In Great Britain the non-identity of typhus and typhoid was clearly
established at Glasgow, where from 183G to 1838 A. P. Stewart studied
the continued fevers, and in 1840 published the results of his observations.
In the decade which followed many important works were issued and
more correct views gradually prevailed ; but it was not until the publica-
tion of Jenner's observations between 1849 and 1851 that the question
was finally settled in England.
Etiology. — Typhoid fever prevails especially in temperate climates, in
which it constitutes the most common continued fever. Widely distrib-
uted throughout all parts of the United States and Canada, it probably
presents everywhere the same essential character.
It prevails most in the autumn months. Of 1,889 cases admitted to
the Montreal General Hospital in twenty years, more than fifty per cent
TVI'IKHI) I'KVKIt. 3
wuro in tlir inoiillis of Au^nist, ScpUiinlHT, uiul (Jclolwr. Of 1,381 ciumm
trcjitcd (liirin<^ twrlvc yfurs iit the 'J'onmto (n-nrnil IIoHpitiil, 7<I1 •H-cMirri'^J
in these inontli.^ ((iniliain). It has hccn well cuIUmI the iiiitiiriiiial fi-v<-r.
It has h(»t'ii oljsiTVcd to prevail most in hot and dry rtru.H<inM. Acrord-
in^ to IVtti^nkofcT, cpichMnics arc? nioHt corniiion whc-n the ^round-wut«r U
low, under which riicnnistanci's th(? springs and watcr-Hoiin-'CH drain more
thoroughly contjuuiiuitrd foci and are nioro likely to bu highly char;/«d
witli poison. It may he also, as Haurngarten suggestH, that in dry seawjnH
tho poison is nu)re disseminated hy the dust.
Males and females are ahoiit ecpially liable to tho disease, but nnalcH
with typhoid are much more? fre(juently admitted into liospiUils.
Typhoid fever is a disease of youth and early adult life. The greatest
susceptibility is between tho ages of lifteen and twenty-five. Of GGO of
tho Montreal cases there were under lifteen years of age, 51 ; between
fifteen and twenty-tive years, 308 ; between twenty-five and thirty-five years,
153 ; between thirty- live and forty-fivo years, 43 ; between forty-five
and lifty-five years, G ; and over fifty-five years, 9. Cases are rare over sixty.
It is not very infrequent in childhood, but infants are rarely attacked.
Murchison has seen a case at the sixth month. It is stated that the disease
may bo congenital in cases in whieli the mother has had the disease late in
pregnancy.
As in other fevers, not all exposed to the infection take the disease,
and there are grades of susceptibility. Some families seem more disposed
to infection than others.
The Specific Germ. — The researches of Eberth, Koch, Gaffky, and
others have shown tliat there is a special micro-organism constantly asso-
ciated with typhoid fever. It is a rather short, thick, motile bacillus, with
rounded ends, in one of which, sometimes in both (particularly in cultures),
there can be seen a glistening round body, believed to be a spore; but
these polar structures are probably only areas of dense protoplasm. It
grows readily on various nutritive media, and on potato in a characteris-
tic manner, as the growtli is invisible. This feature is not peculiar how-
ever to the typhoid bacillus. It is difficult to ditferentiate from the bac-
terium coli commune, except by certain chemical tests. This organism
fulfils two of the requirements of Koch's law — it is constantly present,
and it grows outside the body in a specific manner. The third require-
ment, the production of the disease experimentally by the cultures, has not
yet been met. Probably the animals used for experimentation are not sus-
ceptible to typhoid fever. The bacilli inoculated in large quantities into
the blood of rabbits are pathogenic, and in some instances ulcerative and
necrotic lesions in the intestine may be produced. But similar intestinal
lesions may be caused by other bacteria, including the bacterium colt cam-
mune.
The bacilli produce various poisons, of which Brieger has described a
ptomaine — typhotoxin, and Brieger and Friinkel a toxalbumin ; but our
4 SPECIFIC INFECTIOUS DISEASES.
information on these substances is still very defective. Cultures are killed
at a temperature of 60° C. It is not probable that the typhoid bacillus pro-
duces spores, but it resists drying for days. Bouillon cultures are destroyed
by carbolic acid, 1 to 200, and by corrosive sublimate, 1 to 2,500.
In recent cases of typhoid fever the bacillus is found in the lymphoid
tissues of the intestines, in the mesenteric glands, in the spleen, and in the
liver. It occurs also in irregular clumps in the contents of the intestines
and in the stools. The bacillus is said to have been found rarely in the
blood, in the rose-colored spots (?), and in the urine.
Outside the body the bacilli retain their vitality for weeks in water.
Whether an increase can occur is not yet finally settled. Bolton denies it,
but the general opinion seems to be that such increase may take place to
some extent. They disappear from ordinary water in competition with
saprophytes in a few days. In milk they undergo rapid development with-
out changing the appearance of the milk. They may increase in the soil
and retain their vitality for months. They are not killed by freezing, but,
as Prudden has shown, may live in ice for months. In many epidemics
the bacilli have been detected in the infected water. The detection how-
ever of the typhoid bacillus in drinking-water is by no means easy, and
the question in individual cases must be settled by experts who have had
special experience with this germ. Both Prudden and Ernst have found
it in water-filters.
Modes of Conveyance. — (a) Contagion. — Typhoid fever is certainly
not a very contagious disease, but the possibility of direct transmission
must be acknowledged. The poison is not given off from the skin or in
the breath, but in the faeces. Practically only those persons are liable to
contract the disease in this way who have to do with the stools or with the
body-linen of patients. I have known several instances in which nurses
appear to have been infected under these conditions.
{h) Infection of water is unquestionably the most common mode of
conveyance. Many epidemics have been shown to originate in the con-
tamination of a well or a spring. A very striking one occurred at Ply-
mouth, Pa., in 1885, which was investigated by Shakespeare. The town,
with a population of eight thousand, was in part supplied with drink-
ing-water from a reservoir fed by a mountain stream. During January,
February, and March, in a cottage by the side of and at a distance of from
sixty to eighty feet from this stream, a man was ill with typhoid fever.
The attendants were in the habit at night of throwing out the evacua-
tions on the ground toward the stream. During these months the ground
was frozen and covered with snow. In the latter part of March and early
in April there was considerable rainfall and a thaw, in which a large part
of the three months' accumulation of discharges was washed into the brook,
not sixty feet distant. At the very time of this thaw the patient had nu-
merous and copious discharges. About the 10th of April cases of typhoid
fever broke out in the town, appearing for a time at the rate of fifty a
'i^riKUD I i;vi:it. 5
(Ijiy. Ill all al»nut twelve liuMdnMl jiroph^ wrn> iifTr(!t«M|. An irnriH'TiMo ma-
jority of all llu' cases were in tim [uirt nf the town wliicli rL'(;4)ivc(l wut<T
from I lie infeeled reservoir.
Milk also may Im* tlio houico of irifecrtion. One of tlu' inont tlionni^lily
studicMl i«|)i(lemi('M due to tliin cjiiise was that inve.sti^'ated l)y liuiiard in
Isliiiijtoii. 'riu' milk may !)(» contamiiiattMl by infccicMl water usocl in
(dcansiiig tiio ciins. In fresh milk it hii8 boon Hliown thut the gerniH grow
rapidly.
Filth, had sowers, or cosspools can not in thcniHclvcrt cauHC typhoid
fever, hut they furnish the conditions suitable for the preservation of tlio
bacillus and possibly for its propai^ation.
(r) (htnt(tnn)i(tti(ni of tJiv Siiil. — i'ettenkofer holds that the j)oison is
not eliminated in a condition capable of communicating the diseji^e
directly, but that it must lirst undergo changes in the soil, which changes
are favored by the ground-water.
It does not seem probable that typhoid fever is communicated by the
air alone, as by the nuulium of sewer-gas.
Once in the intestinal canal the typhoid germs jirobalily do not like
the cholera bacilli increase in the secretions, but penetrate the epithelial
lining and reach the lymphoid tissue, upon which they exert their spe-
citic action, causing a cell 2>roliferation greatly in excess of the physiologi-
cal process. The necrosis may be regarded as the result of the maximum
intensity of the action of the bacilli — an action not confined to the lym-
phatic apparatus of the intestinal wall, but also met with in a typical man-
ner in the enlarged mesenteric glands and in the liver and spleen.
It has not yet been definitely determined whether the constitutional
disturbances in typhoid fever depend upon the toxalbumins produced in
the growth of the bacilli, though this is in the highest degree probable.
Morbid Anatomy. — The statistical details under this heading are
based upon sixty-four autopsies, a majority of which were performed at the
Montreal General Hospital, and upon the records of two thousand post-
mortems at the Munich Pathological Institute.*
Intestines. — A catarrhal condition exists throughout the small and
large bowel, and to this is due, in all probability, the diarrhoea with the
thin pea-soup-like stools. xVssociated with this catarrh there is during
life some epithelial desquamation.
Specific changes occur in the lymphoid elements of the bowel, chiefly
at the lower end of the ileum. The alterations which occur are most con-
veniently described in four stages :
1. Ilijperjjlasia, which involves the glands of Peyer in the jejunum and
ileum, and to a variable extent those in the large intestine. The follicles
are swollen, grayish-white in color, and the patches may project to a dis-
tance of from three to five mm. In exceptional cases they may be still more
* Munchener medicinische Wochenschrift, Xos. 3 and 4. 1891.
0 SPECIFIC INFECTIOUS DISEASES.
prominent. The solitary glands, which range in size from a pin's head to
a large pea, are usually deeply imbedded in the submucosa, but project
to a variable extent. Occasionally they are very prominent and may be
almost pedunculated. Microscopical examination shows at the outset a
condition of hyperaemia of the follicles. Later there is a great increase
and accumulation of cells of the lymph-tissue which may even infiltrate
the adjacent mucosa and the muscularis ; and the blood-vessels are more or
less compressed, which gives the whitish anaemic a2:)pearance to the follicles.
The cells have all the characters of ordinary lymph-corpuscles. Some
of them however are larger, epithelioid, and contain several nuclei. Oc-
casionally cells containing red blood-corpuscles are seen. This so-called
medullary infiltration, which is always more intense toward the lower end
of the ileum, reaches its height from the eighth to the tenth day and then
undergoes one of two changes, resolution or necrosis. Death very rarely
takes place at this stage. I have seen but one instance in my series — a
girl, aged twenty-four, who died at the end of the first week with severe
nervous symptoms and in whose ileum the lymph-follicles were greatly
swollen, pitted and cribriform, but without necrosis. Resolution is accom-
plished by a fatty and granular change in the cells, which are destroyed
and absorbed. A curious condition of the patches is produced at this
stage, in which they have a reticulated appearance, the 2>^(^Q.ues a surface
reticulee. The swollen follicles in the patch undergo resolution and
shrink more rapidly than the surrounding framework, or what is more
probable the follicles alone owing to the intense hyperplasia become ne-
crotic and disintegrate leaving the little pits. In this process superficial
haemorrhages may result and small ulcers may originate by the fusion of
these superficial losses of substance.
There is nothing distinctive in the hyperplasia of the lymph-follicles
in typhoid fever. Apart from this disease we rarely see in adults a
marked affection of these glands with fever. In children however it is
not uncommon when death has occurred from intestinal affections. It is
also met with in measles, diphtheria, and scarlet fever.
2. Necrosis and Sloughing. — When the hyperplasia of the lymph-fol-
licles reaches a certain grade resolution is no longer possible. The blood-
vessels become choked, there is a condition of anaemic necrosis, and
sloughs form which must be separated and thrown off. The necrosis is
probably due in great part to the direct action of the bacilli. The process
may be superficial, affecting only the upper part of the mucous coat, or it
may extend to and involve the submucosa. It is always more intense
toward the ileo-caecal valve, and m very severe cases the greater part of
the mucosa of the last foot of the ileum may be converted into a brownish-
])lack eschar. The necrosis in the solitary glands forms a yellowish cap
whi(;h often involves only the most prominent point of a follicle. The
extent to which the necrosis reaches is very variable. It may pass deep
into the muscular coat reaching to or even perforating the peritonagum.
rvi'llnll) l-'KVKlt. 7
.'I. rirn'ntion. — 'I'lin Hr|mruti(tri «»f the iHMToti<j tiHuu*? — tht? hIou^Ihii^ —
is ^^'raduiilly clTiM-tiMl from tin* i'(I;^'«'M iiiwjinl, iimi rrniillH in tin- foriinition
of a?i ulcer, tlic sizti und cxtriit of wliirli arc dirrctly j»ro|)ortioiial«* to iIhj
ivinoiiMl of necrosis. If this he Hiiperlicial, tlio entire tliicknehs of the
nuieosa niav m*! hr iiivnlvcd and the loss of siihstancL* inuy he Hiniili und
shallow. More < omnionly tlu) Hh»U)^h in Hejuiratin^ exj)OHeH the Huhinuc-'owi
and inuscniaris, |>ait icniarly tlui hitter, which forniH thu lloor of a majority
of all typhoid ulcers. It is not common for an entire I'eyer's pat<'h to
slouujh away, aiul a j)erfectly ovoid ulcei- opposite to the m(;Hent4'ry \a
randy seen. Irre^^ularly oval and rounded forms are most common. A
Iar<i;e patch may pn^sent thnn; or four ulcers divide(l hy septa of mucouu
nuMuhrane. The terminal six or eii^dit, incdies of the mucous meml)n4ne
of the ileum nuiy form a lar;^'e ulcer, in which are here and there islands
of mucosa. The t'd^j^es of the ulcer an; usually swollen, soft, sometimes
coni^ested, and often undermined. At Ji late j)eriod the ulcers near the
valve may have very irregular sinuous horders. 'J'he base of a ty})hoid
ulcer is smooth and clean, usually formed of the submucosa or of the
muscularis.
There may be largo ulcers near the valve and swollen hypera^mic
patches of Peyer in the n])j)or })art of the ileum.
4. ncaU)i(j. — This begins with the development of a thin granulation
tissue which covers the base and gives to it a soft, shining appearance.
The mucosa gradually extends from the edge, and a new growth of epi-
thelium is formed. The glandular elements are reformed; the healed
ulcer is somewhat depressed and is usually pigmented. Occasionally an
appearance is seen as if an ulcer had healed in one place and was extend-
ing in another. In death during relapse healing ulcers may be seen in
some patches with fresh ulcers in others.
We may say, indeed, that healing begins witli the separation of the
sloughs, as, when resolution is impossible, the removal of the necrosed
part is the first step in the process of repair. Practically, in fatal cases,
we seldom meet with evidences of cicatrization, as the majority of deaths
occur before this stage is reached.
Large Intestine. — The ca?cum and colon are affected in about one
third of the cases (in nineteen of the sixty-four). Sometimes the solitary
glands are greatly enlarged. The ulcers are usually larger in the caecum
than in the colon. Perforation of the ca?cum is rare. The appendix may
be involved. In my cases there was ulceration in two and perforation in
one case. I dissected a case in Montreal in which the patient died three
months after an attack of typhoid fever, and a localized abscess was found,
due to perforation of the appendix. Death resulted from pylephlebitis.
Perforation of the Bowel. — In one hundred and fourteen cases of the
two thousand Munich autopsies (5*7 per cent) and in fourteen instances
in my series, the intestine was perforated and death caused by peritonitis.
The perforation may occur in ulcers from which tlie sloughs have already
g SPECIFIC INFECTIOUS DISEASES.
separated, or it may be directly due to the extension of a necrosis through
all the coats. In only a few cases is the perforation at the bottom of a
clean thin-walled ulcer. In one instance the perforation occurred two
weeks after the temperature had become normal. The sloughs were, as a
rule, adherent about the site of perforation. A majority of the cases were
in small deep ulcers. There may be two or even three perforations. The
orifice is usually within the last foot of the ileum. In only one of my
cases was it distant eighteen inches. Peritonitis was present in every in-
stance.
Hcemorrliage from the bowels occurred in ninety-nine of the Munich
cases, and in nine of my series. The bleeding seems to result directly
from the separation of the sloughs. I was not able in any instance to find
the bleeding vessel. In one case only a single patch had sloughed, and a
firm clot was adherent to it. The bleeding may also come from the soft
swollen edges of the patch.
The mesenteric glands at first show intense hyperaemia and subse-
quently become greatly swollen. Spots of necrosis are common. In sev-
eral of my cases suppuration had occurred. The bunch of glands in the
mesentery, at the lower end of the ileum, is especially involved. The re-
troperitoneal glands are also swollen.
The spleen is invariably enlarged in the early stages of the disease.
In only one of my cases did it exceed (GOO grammes) 20 ounces in weight.
The tissue is soft, even diffluent. Infarction is not infrequent. Rupture
may occur spontaneously or as a result of injury. In the Munich autop-
sies there were five instances of rupture of the spleen, one of which re-
sulted from a gangrenous abscess.
The liver shows signs of parenchymatous degeneration. Early in the
disease it is hypergemic, and in a majority of instances it is swollen, some-
what pale, on section turbid, and microscopically the cells are very granu-
lar and loaded with fat. Necrotic areas occur in many cases, as described
by Ilandford. They have been studied recently by Reed in Welch's lab-
oratory. No definite association could be determined between the groups
of bacilli and the necrotic areas. In twelve of the Munich autopsies liver
abscess wos found, and in three, acute yellow atrophy. Diphtheritic in-
flammation of the gall-bladder is occasionally met with. This may lead
to perforation and fatal peritonitis.
The kidneys show cloudy swelling, with granular degeneration of the
cells of the convoluted tubules; less commonly an acute nephritis. A rare
condition described by Rayer, Wagner, and others is the occurrence of
numerous small areas infiltrated with round cells, which may have the
appearance of lymphomata (Wagner), or may pass on to softening and
suppuration, producing the so-called miliary abscesses. It is usually
a late change. The bacilli have been found by some observers in these
areas. The bacilli can be obtained by culture from the kidneys, and have
been found in many instances in sections. They have also been found in
TNIMKHI) rKVKIC. 9
iho iiriiH^ ill a r*\v oumoh. Diplitiicritic iiilluriiriialioii of i)u> f><;Ivi« of tha
kidiu^y may occMir. It whh prcHciit in tliruo of my niM'H, in r>nc) of which
ih(i lips of tlic |)apiila» wcm also alToctcMl. Catarrh of thf lihuhh-r in not
uncommon. Diplillicritic; inllammation of il may also occur. Orchitin iii
occasionally iiicl witli.
'I'hc iinaloiiiical cliaii^ts in the rrspird/art/ (irt/fin.s arc not v<?ry numer-
ous. Ulccrat ion of llir larviix occurs in a (certain niimlxT of cascn ; in the
Munich series it was noted oiu* linn(lrc(l and .stjvcn times. It may come on
at tlie saint* time as th(» ulceration in the ileum, hut tin; l>acilli liavo not
yet, I helieve, l)een found in the ulcers, 'i'hey occur in the; post<;rior wall,
at tlie insertion of the cords, at the l)ase of the epi^dottis, and on the ary-
epi<;lottidean foMs. In the later periods catarrhal and diphtiieritif; ulcers
may i)e present.
(Kdenni of the f^lottis wjis present in twenty of the Municli ca.ses, in
ei^ifht of wlii(di tracheotomy was performed. Diplitheritic laryn^'itis is not
very uncommon. It occurretl in a most extensive form in two of my ca-ses.
In one the membrane was chielly in tlie pliarynx, and exten(U'(l only upon
the epiglottis ; in the other there was a uniform membrane wliich extended
into the trachea and in the tubes of the second dimension. In eiglit cases
in my series there was lobar pneumonia. Hypostatic congestion and the
condition of the lung spoken of as splenization are very common. Gan-
grene of the lung occurred in forty cases in the ^lunich series ; abscess of
the lung in fourteen ; hnemorrhagic infarction in one hundred and twenty-
nine. Pleurisy is not a very common event. Fibrinous pleurisy occurred
in about six per cent of the Munich cases, and empyema in nearly two per
cent.
Changes in the Circulatory System. — Endocarditis is rare. It was not
present in any of my cases, and existed in eleven only of the Municli
autopsies, in which also there were fourteen cases of jDericarditis. Myo-
carditis is not very infrequent. Dewevre,* in a series of forty-eight
cases, found in sixteen granular or fatty degeneration, and in three a pro-
liferating endarteritis in the small vessels. It is remarkable that even in
cases of death from heart-failure, with intense fever, the cell-fibres may
present little or no observable change. The arten'es are not infrequently
involved in tvphoid fever. Barie distins^uishes an acute obliteratins: arteri-
tis and a partial arteritis, and states that they both occur most commonly
in the arteries of the lower extremities. They are responsible, no doubt,
for certain of the cases of blocking of the arterial trunks. This arteritis
may affect the smaller vessels, particularly those of the heart. In the
veins, tlirombi are not infrequently found, particularly in the femoral
veins, and more rarely in the cerebral sinuses.
Nervous System. — There are very few coarse changes met with. Men-
ingitis is extremely rare. It was not present in any one of my autop-
* Archives generates de Medecine, 1887, 2.
10 SPECIFIC INFECTIOUS DISEASES.
sies, and occurred in only eleven of the two thousand Munich cases. The
anatomical lesion upon which the aphasia — seen not infrequently in chil-
dren— depends, is not known. Possibly, as Leyden states, it may be due
to slight encephalitis. Parenchymatous changes have been met with in
the peripheral nerves, and appear to be not very uncommon, even when
there have been no symptoms of neuritis.
The voluntary muscles show, in certain instances, the peculiar changes
described by Zenker which occur in all long-standing febrile affections
and are not peculiar to typhoid fever. The muscle substance within the
sarcolemma undergoes either a granular degeneration or a hyaline trans-
formation. The abdominal muscles, the adductors of the thighs, and the
pectorals are most commonly involved.
Symptoms. — In a disease so complex as typhoid fever it will be
well first to give a general description and then to study more fully the
sypmtoms, complications, and sequelae according to the individual organs.
General Description, — The period of incubation lasts from a week to
ten days, during which there are feelings of lassitude and inaptitude for
work. The onset is rarely abrupt. There may be prodromal symptoms,
either a rigor, which is rare, or chilly feelings, headache, nausea, loss of
appetite, pains in the back and legs, and nose-bleeding. These symptoms
increase in severity and the patient at last takes to his bed. From this
event, in a majority of cases, the definite onset of the disease may be dated.
During the first iceek there is, in some cases (but by no means in all, as
has long been taught), a steady rise in the fever, the evening record rising
a degree or a degree and a half higher each day, reaching 103° or 104°.
The pulse is rapid, from 100 to 110, full in volume, but of low tension
and often dicrotic; the tongue is coated and white; the abdomen is
slightly distended and tender. Unless the fever is high there is no de-
lirium, but the patient complains of headache, and there is mental con-
fusion and wandering at night. The bowels may be constipated, or there
may be two or three loose movements daily. Toward the end of the week
the spleen becomes enlarged and the rash appears in the form of rose-
colored spots, seen first on the skin of the abdomen. Cough and bron-
chitic symptoms are not uncommon at the outset.
In the second week^ in cases of moderate severity, the symptoms be-
come aggravated ; the fever remains high and the morning remission is
slight. The pulse is rapid and has lost its dicrotic character. There is
no longer headache, l)ut there is mental torpor and dulness. The face
looks heavy ; the lips are dry ; the tongue, in severe cases, becomes dry
also. The abdominal symptoms are more marked — diarrhoea, tympanites,
and tenderness. Death may occur during this week, with pronounced
nervous symptoms, or, toward the end of it, from ha}morrhage or perfora-
tion. In mild cases the fever declines, and by the fourteenth day may be
normal.
In the third week, in cases of moderate severity, the pulse ranges from
'\'\ nmii. i'i:vi;it. 11
llii l(> l.'lo; liio tniiprrHtiirn now mIiowh iimrktMl riiornin^ reiniMxiotiM, urifl
tluM't) is li ;^M-!i<liml (Icrliiir ill \\u) (over. 'IMio Iohm of ll(*Mh in now nioro
noticiMihlc, aiiti t li(^ wciikiicsH is piniioiincrd. TIh- diurrho'ii iiti<l nich-or-
JHiii riHiy persist. riiruv(trui)I(* HviiiptoriiH ut thin Hlii^o urn tin* pitlnio-
imry cofiipliciilionM, iucriMiHiii;,' fccMoiicHH of tlio hourt, uiul pronouiKrcd
(loliriiiin witli nmscular tremor. Special diiu^urH urt; pcrforution uiid
luemorrlm^o.
With i\\{) /'()(( rf/i trrilx\ in :i majority of instances, convulo«cenoo be-
ijjinM. The temperatun! jj^i'adiially readies i\\{\ iioi-mal point, tho diurrhcDa
stops, the toiiiriie eU'aiis, and (lie desire for food returns. In seven; ciwc.s
the foiirtli week may present an a;.(;j[ravate(l ])ietnrt! of the third; the
patient ^rows weaker, the pulse is inon; rapid and feehlo, the tonj^uo dry,
and the alxlomen disti'iided. lie lies in a condition of profound Htuj)or,
with low muttering delirium and suhsultus tendinum, and pas.so8 the
fan'es and urine involuntarily. Ih-art-failurt; and seconchiry complications
are the eliief danjj^ers of this })i>riod.
In the ///■/// and si.rtlt week's i)rotraeted cases may still show irregular
fever, and convalesccnco may not set in until after the fortieth day. In
this period we nu»et with relapses in the milder forms or sliglit recru-
descence of the fever. At this time, too, occur many of the complications
and se(iuehe.
Special Features and Symptoms. — Mode of Onset. — As a rule, the
sym})toms develop insidiously, and the patient is unahle to fix definitely
the time at which he began to feel ill. The following are the most im-
portant deviations from this common course :
(^7) Onset with Pronounced Nervous Manifestations. — Headache, of a
severe and intractable nature, is by no means an infrequent initial symp-
tom. Again, a severe facial neuralgia may for a few days put the practi-
tioner off his guard. In cases in which the patients have kept about and,
as they say, fought the disease, the very first manifestations may be pro-
nounced delirium. Such patients may even leave home and wander about
for days. In rare cases the disease sets in with the most intense cerebro-
spinal symptoms, simulating meningitis — severe headache, photophobia,
retraction of the head, twitching of the muscles, and even convulsions.
Occasionally drowsiness, stupor, and signs of basilar meningitis may exist
for ten days or more before the characteristic symptoms develop ; occasion-
ally the onset is with mania.
(h) With Pronounced Pulmonary Si/mptoms. — The initial bronchial
catarrh may be of great severity and disguise the other features of the
disease. More striking still are those cases in which the disease sets in
with a single chill, with pain in the side and all the characteristic features
of lobar pneumonia.
(r) With Intense Gastro-intestinal Symptoms. — The vomiting may be
incessant and uncontrollable. Occasionally there are cases with such in-
tense vomiting and diarrhoea that a suspicion of poisoning may be aroused.
12
SPECIFIC INFECTIOUS DISEASES.
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{)/) With Si/in/)fntfis of tin Arutti Ar/t/iritiM. — Smoky or bloo<ly urine,
witli iiiiK-li iilltiniicii luid (til)(^-(!iistH.
(/') Anihttlitloni /'W/v//. -Deserving of cHprcial lucntioii tin* tlioMo caMf
of typlioid f(>V( r in wliich tlu* piitinit keeps iilxnit mid uttciii))U to do
work, or pcrluipM tukuH x\ lon^ joiiriu^y to liin hoiiK*. Ho may como umler
obscM'vjitioii f(»i- till' lirHt timu with u tciiipunituru of 101 ' or JO.V, und the
nisli well out. Such oasos hooiu ulwiiys to run u riioru hovcto courne than
others, and in ^^cnend liosj)itals they contribute lur^^'ly to tlu^ total mor-
tality. I'^inally, then» are rare instances in wliich the lirst symptoms are
perforation, oi* a profuse Ini'morrha^^o from the bowids.
Facial Aspect. — Karly in tho disease the cheeks arc flushed and the
oyos brii^^ht. Toward the end of the lirst week the (ixpression }>ecome8
more listless, and when tho disease is well established the expression is dull
and heavy.
Fever. — (a) Iirt/ular (^onrse. (Chart I.) — In the sta^c of invasion
the temi)erature may rise steadily durin<^ the first live or six days. The
evening temperature is about a degree or a degree and a half higher than
the morning remission, so that a temperature of 104° or 105° is not un-
common by tho end of the first week. Having reached the fastigium or
height, the fever then persists witb slight morning remissions. The tem-
perature curve follows the normal diurnal variations, the maximum oc-
curring between four and eight o'clock in tlie evening and tlie minimum
between four and eight in the morning. At the end of the second and
throughout the third week the temperature becomes more distinctly re-
mittent. Tlie dilference between the morning and evening may be three
or four degrees, and the morning temperature may even be nornuil. It
falls by gradual lysis, and tlie temperature is not considered normal until
the evening record is at 98*2°.
{!)) Variations in tho normal temperature curve are common. We do
not ahvays see the gradual step-like ascent in the early stage ; the cases
do not often come under observation at this time. When the disease sets
in with a chill, the temperature may rise at once to 103° or 104°. In
many cases defervescence occurs at the end of the second week and the
temperature may fall rapidly, reaching the normal within twelve or twenty
hours. An inverse type of temperature, high in the morning and low in
the evening, is occasionally seen but has no especial significance.
Sudden falls in the temperature may occur ; thus, as shown in Chart
IV, a drop of 10° may follow^ an intestinal haemorrhage, and the fall may
be very apparent even before the blood has appeared in the stools. Hy-
perpyrexia, temperature above 106°, is not very common in typhoid fever
except just before death, when I have known the thermometer to register
109-5°. (Chart II.)
{c) Post-Tijplioid Elevations — Fever of Convalescence. — During con-
valescence, after the temperature has been normal, perhaps for five or
six days, the fever may rise suddenly to 102° or 103°, and, after per-
14
SPECIFIC INFECTIOUS DISEASES..
sisting for from one to three days or even longer, falls to normal. With
this there is no constitutional disturbance, no furring of the tongue, no dis-
tention of the abdomen. These so-called recrudescences are by no means
uncommon, and are of especial importance, as they cause great anxiety to
the practitioner. Th*y are attributed most frequently to errors in diet,
constipation, emotions, and excitement of any sort, such as seeing friends.
There are cases in which the temperature declines almost to the nor-
mal at the end of the third week, the tongue cleans, and the patient enters
Oct. iG
20
2i
Temp,
109
108
107
106
105
101
103
102
101
100
Pay of
Disease
^■•
Pulse
Re&p.
: i
•:--Aii
r
\ •
• •
1 t-
t
190
180
170
75
70
1
\ \
y;
i
1
160
150
110
65
60
55
\
-■■\
jAr
vd:i\
:.
: ■
ftl
.; I
130
120
50
45
► •.
:
■•r ;
• • •
110
100
35
11
12
13
14
15
IG 1
7 18
19
CuART II. — Hyperpyrexia — death.
apparently upon a satisfactory convalescence. The evening temperature,
however, does not reach 98-5°, but constantly keeps about 99-5° or 100°,
and occasionally rises to 100-5°. This, in the late stages of convalescence,
I have seen due to the post-typhoid anaemia. Complications should be
carefully looked for, particularly insidious pleurisy or bone lesions.
In certain of these cases the persistence of the fever seems to be really
a nervous phenomenon, and there is nothing in the condition of the
patient to cause uneasiness except tlie evening elevation of temperature.
If the tongue is clean, the appetite good, and there are no intestinal
symptoms, it may be disregarded. I have frequently found this condition
best met by allowing the patient to get up and by stopping the use of the
thermometer. This prolonged slight elevation of the fever after the dis-
TV n loll) KKVKIC. 16
ap)M'!initi('(« oT iill lli() HyiMptoriiH in imohI nomninfi in chililn?!! and in
jMitirnlM of marked nrrvoiis trniiH'ninM'nt.
{</) Tin' /•'ri'rr (if f/ir lirldjisf. -TIum i« u n-prtiliun in rniiny inMUnccM
of the orin^iiml fr\<'r, a ;,'nidiml iiHccnt and rnaint<!nafjc<5 for a few day» at
a (-(Tlaiit liciLrlil 'I'ld iIk-ii u Knidiial drcliiu;. It in Hhortcr tluiii the original
j)yri»xia, jmhI rarely <*niiliiiiies mnic iliaii twn or thrccj wcokH. (Chart I.)
(v) Afchrilc Tiipltuid. — 'I'lieic arc caHes denerila'd in wliieli tlio chief
foaturt's of th(» disease have Iteeii present without the existence of fever.
'Pliey are exli'emely rare '\\\ this country. No itistance (.f fin- kind }ijib
oonie under iiiy ohservatioii.
Skin. — 'I'hc rash of typhoid fever is very characteriHtic. It conHiHts
of a nuiulter of rose-eoh)red spots, w hieh appear from the Hcventh to the
tenth (hiy, usually lirst upon the al)(h)nien. The spots are flattened
papul(\s, slii^iitly raised, of a rose-red (!oh)r, disappearing^ on pressure, and
ranij^inuj in diameter from two to four millinu'tres. They can Ik' felt as
distinct eU'vations on tlio skin. Sometimes each spot is capped hy a small
vesicle. 'Phe spots may be dark in color and occasionally become pete-
chial. After persisting for two or three days they gradually disap})ear,
leaving a brownish stain. They come out in successive crops, but rarely
appear after the middle of the tliird week. They are present in the typ-
ical relai)se. 'Phe rash is most abundant ujion the abdomen and lower
thoracic zone and often abounds upon the back. It is extremely variable
in degree. There are cases in which it spreads to the extremities and often
to the face. I can not say that in my experience these cases with the
more abundant eruption have been of specially severe type. The rash is
not always present. Murchison states that it is frequently absent in
children.
A branny desquamation is not rare in cases in which the sudaminal
vesicles have been abundant; occasionally the skin may peel in large
flakes.
The following accidental rashes are met with in typhoid fever :
1. Erythema. — It is not very uncommon in the first week of typhoid
fever to find the skin of a vivid red color, almost like a scarlatinal rash.
This is particularly noticeable on the abdomen and chest, but the rash
may spread to the extremities. It may possibly in some instances, but
certainly not always, be due to quinine. I have seen it much more fre-
quently in the past five years (during which time I have rarely ordered
a dose of quinine in this disease) than I did in Montreal, where we used
quinine largely as an antipyretic.
2. The tache hJeudfre — Peliomata. — These are pale-blue spots, subcu-
ticular, from 4 to 10 mm. in diameter, of irregular outline and most
abundant about the chest, abdomen, and thighs. They sometimes give a
very striking appearance to the skin. It can be readily seen that the in-
jection is in the deeper tissues and not superficial. This rash is quite
without sififnificance. Since mv attention was called to its association with
16 SPECIFIC INFECTIOUS DISEASES.
body lice, I have met with no instance in which these were not present.
Several French observers maintain that they are due to the irritating
effects of the fluid secreted by pediculi.
3. Sudaminal and miliary eruptions are common in all cases in which
there is profuse sweating.
4. Urticaria is occasionally met with, and lastly herpes, but this is un-
common in comparison with its frequency in malaria and pneumonia.
The tache cerebrale^ a red line with white borders, can be produced
by drawing the nail over the skin. It is a vaso-motor phenomenon which,
as in other fevers, can be readily elicited, particularly in nervous sub-
jects. Here may be mentioned certain other cutaneous phenomena also
of vaso-motor nature : thus exposure of the abdomen may be sufficient to
cause a pinkish injection, which may in places change to an ivory white,
giving a curious mottled appearance to the skin. A similar appearance
may be seen on the arms. The general tint may be white, with irregu-
lar patches or streaks of pink or dark red.
Sweats. — At the height of the fever the skin is usually dry. Profuse
sweating is rare, but it is not very uncommon to see the abdomen or chest
moist with perspiration, particularly in the reaction which follows the
bath. Sweats in some instances constitute a striking feature of the dis-
ease. They may occasionally be associated with chilly sensations or actual
chills. Jaccoud and others in France have especially described this
sudoral form of typhoid fever. There may be recurring paroxysms of
chill, fever, and sweats (even several in twenty-four hours), and the case
may be mistaken for one of intermittent fever. The fever toward the
end of the second week and during the third week may be intermittent.
The characteristic rash is usually present, and if absent the negative con-
dition of the blood is sufficient to exclude malaria. I have seen cases of
this form in Montreal, where there could have been no suspicion of ma-
larial infection.
CEclema of the skin occurs :
1.. As the result of vascular obstruction, most commonly of a vein, as
in thrombosis of the femoral vein.
2. In connection with nephritis.
3. In association with the anaemia and cachexia.
The hair is very apt to fall out after an attack of typhoid fever. In-
stances of permanent baldness are of extreme rarity. As in other diseases
associated with fever the nutrition of the nails suffers, and during and
after convalescence a transverse ridge is seen.
And, lastly, it is stated that a peculiar odor is exhaled from the skin in
typhoid fever. Whether due to a cutaneous exhalation or not, there cer-
tainly is a very distinctive smell connected with many patients. I have
repeatedly had my attention directed to it by nurses. Nathan Smith
descriV)o.s it as of a " somi-cadaverous, musty character."
Circulatory System. — The blood presents important changes. The
TVi'iiniD i''i:vi:u. 17
following HtutciruMilH jin^ IhimimI oh HtiidicM whirh W. S. Thuy(?r hiw tuiults
ill my wiinl. hiiriii;^' llw lirHt two wcrkH tlirrc Fiiuy Im* littlo or no clian^e
in tih^ hloitii. I'lofiiso HwrutM or (M»piouH (liiirr)i<i'>i may, im Iluyi'm hof
bIiowii, ciiiiHC' (he cnrpMsclcs HH ill tin- <'olliip.m« Htu;^^* of (;lioirni — U> riMC*
a1)()V(^ iKtrmal. In ilir ihinl week a fall iisiialiy tJikcH phico in (;orpit>K;leH
and lia'?ii(i;^dol»iii aiid llic Milliliter may hiiik rapidly t'vcn to 1,.'J()0,()0() j>ct
V. mm., ;;radiially rising to normal iliirin;^ (;onval('.Hc(?n(!0. When the
])ati(>iit lirst ^I'ts up, tline may l»«' a Hli;;lit, fall in the number of tlio for-
puscK's.
Tlic amount of li;inio^dol)iii is always n-ducrcl, and usually in a greater
relativo proportion than the numltcr of red (M)rpU8(de8, and during rccov-
ory the normal color standard is reached at a later period. 'I'iie numl>er
of colorless corpuscles varies littli? from the normal stanchird (fl,0()0 ± per
0. mm.). As a rule, perhaps the numher is sli;(htly subnormal (I*ee).
This fact is important, and may he at times of real dia<,Miostic value in
distiiiguishinij;; typhoid fever from various sej)ti(! fevers and auute iullum-
matory processes in which there is leucocytosis.
Tlie accompanying blood-chart shows tliese changes well.
The post-typhoid aiuemia may reach an extreme grade. In one of my
cases the blood-corpuscles sank to 1,3{)0,()0() per cubic mm. and the haemo-
globin to about twenty i)er cent. These severe grades of amemia are not
common in my experience. In the Munich statistics there were fifty-
four cases with general and extreme anjemia.
Of changes in tlie blood plasma very little is known.
The pulse in typhoid fever presents no special characters. It is in-
creased in rapidity in i)roportion to the height of the fever. As a rule, in
the first week it is above 100, full in volume and often dicrotic. There is
no acute disease with which, in the early stage, a dicrotic pulse is so fre-
quently associated. Even with liigh fever the pulse may not be greatly
accelerated. As the disease progresses the pulse becomes more rapid,
feebler, and small. In the extreme prostration of severe cases it may
reach 150 or more, and is a mere undulation — the so-called running pulse.
The lowered arterial pressure is manifest in the dusky lividity of the skin
and coldness of tlie hands and feet.
During convalescence the pulse gradually returns to normal, and occa-
sionally becomes very slow. After no other acute fever do we so fre-
quently meet witli bradycardia. I have counted the pulse as low as
thirty, and instances are on record of still fewer beats to the minute.
The hearf-sonnds are at first clear and loud, and free from murmur,
but in severe cases, as the prostration develops, the tirst sound becomes
feeble and there is often to be heard, at the apex and along the left sternal
margin, a soft systolic murmur. The first sound may be gradually anni-
hilated, as pointed out by Stokes. In the extreme feebleness of the ataxic
forms, the first and second sound become very similar and the long pause
is much sliortened.
18
SPECIFIC INFECTIOUS DISEASES.
Of cardiac complications, pericarditis is rare and has been met with
chiefly in children and in association with pneumonia. It was not pres-
ent in any of my cases and occurred in only fourteen of the two thousand
5,000,000
DEC , 1890
JANUARY, 1891
FEBRUARY
MARCH -j
100;i
19
22
25
28
31
3
6
9
12
15
18
21124
27
30
2l5
8
1 1
14l 17
20123
26
1
4
7
10
13
16 19
-
90%
80^
4,000,000
fk
1
A
70;?
\
/
\
/
f
60;g
3,000,000
1
/
1
/
/
50^
/
f
,^
J
\
/
/
^
40^
2,000,000
^
y
/
r
r^
^
-<
r
\
s.
/
/
/
r
30;?
\
\
y
/
/
^
><
^
X,
1
20;g
1,000,000
10^
500,000
1
1
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1^
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10,000
/
8,000
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k
6,000
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r^
,— '
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4,000
•
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2,000
\
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/
,
MEAN NORM.
NUMBER OF
WHITE
CORPUSCLES
BLACK, RED CORPUSCLES.
RED, HAEMOGLOBIN.
Chart III.
BLUE, COLORLESS CORPUSCLES.
Munich post-mortems. Endocarditis is also uncommon. I saw one case
at the Pliiladelphia Hospital. It must be very rare, as there were only
eleven cases noted in the Munich records. Myocarditis is more common.
The following statement may be made with reference to the condition of
the heart-muscle in this disease : In protracted cases the muscle-fibre is
usually soft, flabby, and of a pale yellowish-brown color. The softening
may be extreme, though rarely of the grade described by Stokes, in which,
when held apex up by the vessels, the organ collapsed over the hand.
'\\ I'llnlh I'KVKU. 19
forrniiiL^ ii rniisliinnin Iil<c cap. MicnmcojMciiIly, ilic ril)rcM mny hliow Iittl<;
nr no rli.iii;^'!', cNrii \\ hrii llic iiupiiUc of ilir heart haH Imm-ii extn-iiH'ly ftn?-
I)l('. A ^^niiiiulMi* pan'McliyiimlniiM •IcLrcucnitioii in coiMriion. Katty <l«"j^'cri-
tM'alion limy ln« prcsnit, particularly in lnii;^'-stari(liM;^' caxiM with aii.i'riiiiu
Tlu^ hyaliiK" cliaii;^'(? in not cnmrnnn. TIm? Hc;,nncntin^ inytx-anlitin, in
which \\\o ccincnl sulistanct^ in H(>ft4'!io(l ho that tlm niiiK<'h*-cellH Hcpunite,
has also hccii fniind, l»iil il is prnhal»l\ a post -rn(»rlcrn change.
(oni/tlinthOfis in I he Arhrics. — Ohliteration of lar^'c or Hriiall arterial
trunks is oiui o{ {\w raro coniplications of typhoid fever. A consithTahlo
nun»l)cr of cases arc scat tercel throu;^'li tlu^ literature. The ohliteratif)ii
may ho duo either to eniholisni or to thronihosis. In a majority of ca.ses
tho femoral artery is involved and pin«^rene of tlio foot and leg occurs.
In scn'oral cases there has heen ohliteraiioii of hoth femorals with extension
of the clot into the aorta and ganj^rene of hoth \v'j[>. In a case which I
saw witli Iioddiek, of Montreal, the ohliteralion of tlu; left fem<jral
occurred on tho sixteenth day. On the twentieth day the patient liad
])ain in tho right leg and there was no pulsation in the femoral artery.
Gangrene gradually developed in hoth feet, and death took place in the
sixth week. In these cases the condition is prohahly due to thromhosis,
not cmholism, and is associated with a blood state which favors clotting,
or possibly with a local arteritis. The condition is not invariably fatal.
Of twenty cases collected by Barchoud,* eight died.
Thrombi in the Veins. — This is a much more frequent complication,
and, according to ^[urchison, is met with in about one per cent of the
cases. It occurs most frequently in a crural vein, and more commonly in
the left than in the right ; due possibly, as suggested by Liebermeister, to
the fact that the loft common iliac vein is crossed by the right iliac
artery, and does not permit of so free a flow of blood as in the right vein.
Thrombosis is indicated by enlargement and a}dema of the limb, but gan-
grene never results from obstruction of the vein alone. It is not a very
unfavorable complication. In one case of my series the thrombus had
suppurated and there was pvf^mia. Occasionally the thrombosis may
extend into the pelvic veins and into the vena cava. In one instance the
thrombus was in the right circumflex iliac vein alone, and the superficial
veins on the right side of the abdomen were in consequence greatly en-
larged. Sudden death has been caused by dislodgment of a thrombus.
Infarcts in the kidneys, spleen, and lungs are by no means uncommon
in typhoid fever. They are associated usually with thrombosis in the
arteries, rarely with embolism.
Digestive System. — Loss of appetite is early, and, as a rule, the relish
for food is not regained until convalescence. Thirst is constant, and
should be fully and freely gratified. Even when the mind becomes be-
numbed and the patient no longer asks for water, it should be freely given.
* Paris Thesis. ISSl.
20 SPECIFIC INFECTIOUS DISEASES.
The tongue presents the changes inevitable in a prolonged fever, but there
are no distinctive characters. Early in the disease it is moist, swollen,
and coated with a thin white fur, which, as the disease progresses, becomes
denser. It may remain moist throughout. In severe cases, particularly
those with delirium, the tongue becomes very dry, partly owing to the
fact that such patients breathe with the mouth open. It may be covered
with a brown or brownish-black fur, or with crusts between which are cracks
and fissures. In these cases the teeth and lips may be covered with a dark
brownish matter called sordes — a mixture of food, epithelial debris^ and
micro-organisms. By keeping the mouth and tongue clean from the out-
set the fissures, which are extremely painful, may be prevented. During
convalescence the tongue gradually becomes clean, and the fur is thrown
off, either insensibly or occasionally in flakes.
The secretion of saliva is often diminished ; salivation is rare.
Parotitis is not so common as in typhus fever. It was present in
forty-five of the two thousand Munich cases. It did not occur in any of
my series of fatal cases. It is usually unilateral, and in a majority of
cases goes on to suppuration. It is regarded as a very fatal complication,
but recovery has followed in four or five of my cases. It undoubtedly
may arise from extension of inflammation along Steno's duct. This is
probably not so serious a form as when it arises from metastatic inflam-
mation.
The pliarynx may be the seat of slight catarrh. Sometimes the fauces
are deeply congested. Membranous pharyngitis is a serious and fatal
complication, which may come on in the third week.
The gastric symptoms are extremely variable. Nausea and vomiting
are not common. There are instances, however, in which vomiting, re-
sisting all measures, is a marked feature from the outset, and may directly
cause death from exhaustion. Vomiting does not often occur in the sec-
ond and third week, unless associated with some serious complication. In
a few of these cases ulcers have been found in the stomach.
Of intestinal symptoms, diarrhoea is the most important. In some
epidemics constipation exists, but in any long series of cases diarrhoea
will be found to be a prominent feature of the disease. Its absence must
not be taken as an indication that the intestinal disease is of slight ex-
tent. I have seen, on several occasions, the most extensive infiltration
and ulceration of the Peyer's glands of the small intestine, with the colon
filled with solid faeces. The diarrhoea is caused less by the ulcers than by
the associated catarrh, and, as in tuberculosis, it is probable that when this
is in the large intestine the discharges are more frequent. It is most
common toward the end of the first and throughout the second week, but
it may not occui until the third or even the fourth week. The number
of discharges ranges from three to eight or ten in the twenty-four hours.
They are usually abundant, thin, grayish-yellow, granular, of the con-
sistency and appearance of pea-soup, and resemble very much, as Addison
'rVriKHh FKVKK.
21
rorniirkcd, tlif iiornuil rofitcntH of tin* Mriiull howi'l. Tim n-artioii in alku-
liiKMUid llin odor nlTi'iiHivc. On Hliiiiiiiii^, tlid diMiliur^n'H Hi'|iunito into u
thill H(M*ouM luvcr, roiitaiiiiii^ iilhiiinrii uiid huUh, and a lower Htratiitiif coii-
Bintin^ of «'|)itli('lial dihris, nMimaidH of food, and rninicroiiH (^ryxtuli of
triple phoKpliatos. Hlood may bo in Hinall amount^ und only recognized
I
IS§iaS8B8i«
1 I . M t ! I M I I I I ! I I M M j I I i ' ' ' ! I i i ^
-.1 '»9
••■•'•••■ '-j} . -....v. ......
;t«M>|l pMOtooCvto -n
....^.. ...... ..*... ,
,.;...>.4..;...;...j...>..*
•v:"Y
•♦••i--4
::H::i::ttiii ■
4 Tj"v-i-tl"v •
:...i..^.^..^..;../...^..•...i..:.'^i!..T.%/...i..:..^..: ..;...■.■?... ..Oi=--i-----fc--V"*""-*'^t--'-
:;::"::::::: •jy.:-y»; '• \ : : ■ •ai\ [O.za • ! = ; • :S: :Si _
:...!...•... ^.. •...:...:...;... v. ^.:}t.«l.h.S^;...'....^..'.../...^..;5j ..;*,.;...:. .J... ^..^ j...i.,,:m;...'J.- —
•• S5 e* ^
<< r— • V«P S^f •W K^ ^^ %w* >»' ^^ «W ^
o = =5
^ 5-
2,
O
t: - '^ >
by the microscope. Sloughs of the Peyer's glands occur either as gray-
ish-yellow fragments or occasionally as ovoid masses, an inch or more in
length, in which portions of the bowel tissue may be found.
Hcemorrhage from the bowels is a serious complication, occurring in
from 3 to 5 per cent of all cases. It occurred in ninetv-nine of the two
22 SPECIP^IC INFECTIOUS DISEASES.
tliousand Munich autopsies, and it was present in nine of my cases. There
may be only a slight trace of blood in the stools, but too often it is a pro-
fuse, free haemorrhage, which rapidly proves fatal. It occurs most com-
monly between the end of the second and the beginning of the fourth
week, the time of the separation of the sloughs. Occasionally it results
simply from the intense hyperaemia. It usually comes on without warn-
ing. A sensation of sinking or collapse is experienced by the patient, the
temperature falls, and may, as in the annexed chart, drop eight or ten
degrees in a few hours. Fatal collapse may supervene before the blood
appears in the stool. Haemorrhage usually occurs in cases of considerable
severity. Graves and Trousseau held that this was not a very dangerous
symptom, but statistics show that death follows in from thirty to fifty per
cent of the cases.
It must not be forgotten that melaena may also be part of a general
hgemorrhagic tendency, in which case it is associated with petechiae and
haematuria.
Meteorism is a frequent symptom, and if of moderate grade is not
serious, but when excessive it is usually of ill-omen. Owing to defective
tone in the walls, in severe cases owing to infiltration with serum, gas ac-
cumulates in the small and large bowels, particularly in the latter. It is
rightly held to be to some extent a measure of the intensity of the local
lesions. When extreme, it pushes up the diaphragm and interferes very
much with the action of the heart and lungs. It undoubtedly also favors
perforation.
Abdominal tenderness on pressure and gurgling in the right iliac
fossa exist in a large proportion of all the cases. The tenderness may be
more or less diffuse over the abdomen, but it is commonly limited to the
right side It is rarely excessive and may be elicited only on deep press-
ure. Gurgling indicates simply the presence of gas and fluid faeces in
the colon and caecum.
Perforation of an ulcer into the peritonaeum, the most serious abdom-
inal complication of the disease, occurred in one hundred and fourteen of
the two thousand Munich cases, and in fifteen of the sixty-four cases of my
series It is usually indicated by the onset of sudden acute pain in the
abdomen, and symptoms of collapse. It is most common at the end of the
second or in the third week, but in one of my cases it occurred as early
as the eighth day and in another in the sixth week, two weeks after the
evening temperature had become normal. It is not infrequently associated
with haemorrhage. The presence of indigestible food, severe vomiting,
excessive meteorism, and ascaridcs have been assigned as causes. This
accident is much more common in men than in women. The perforation
is usually in the ileum, but may occur in the colon. As a rule it promptly
causes symptoms of peritonitis — distention of the abdomen, marked ten-
derness, rigidity of the abdouiinal walls, vomiting, a collapsed, pinched
expression, and a rapid, smjiU pulse. In very severe cases with marked
TVi'iioiD ri:\ r.u. 28
innital (listiirliaiicr t)i<> KyinphwiiM iiiay not oxcito MUMiiicioii, hut tliL* tern-
prrutiin* usually fallH iiiul tlu* HyniptoiiiH of (;oIlupHo lire well niurkcd. Tim
(lia^^niosis is rasy, cxcrpt in vuhvh in wlii(;h lynipanilcH iiihI ivtulvnwHn
have Ix'cn prominent fratuics, wlu-n i( nuiy Im- vny (liniciilt to Muy ulirllior
pci'Toration lias occurred. An indication of value in hucIi inHt^inceM Im the
ohlitoration of I he liver dulness l»y ^'as in tin? peritoneal cavity, u Hynijitorn
upon which Alon/o Clark and I'linl laid ^reut KtresH, and the vuliie of
which 1 have on several occasions heen aide to demonstrate. It i.s Konic-
what lesseiu'tl hy the fact that extreme tympany nniy almost, if not quite,
ohlilt»rate tht» liver dulness. Recovery from perforation is undouht<'dly
])()ssil)I(», thou«,di rare.
Peritonitis without j)crforati(»ii may also occur by extension from the
ulcer or occasionally hy rupture of a softened mesenteric gland. It waa
present in *v'v per cent of the Munich autopsies.
The spleen is invariahly enlari^ed in typhoid fever, and in a majority of
cast\s the edj^e can he felt below the costal mar^jin. Uy the end of the first
week tlie enlar«;ement is evident, unless there is ^reat distention of the
coh)n, when the sjdeen may be ])ushed far back and difHcult to feel. Even
[\\v normal area of dulness may not be obtainable. I have seen a very large
spleen post mortem, when during life the increase in size was not observ-
able. Toward the fourth week it diminishes in size. In four of my
auto})sies it weiglied less than normal. Infarcts and abscesses are occa-
sionally found. Rupture of the spleen in ty])hoid fever, due to a slight
blow, has been seen by Bartholow. Spontaneous rupture may also occur.
Liver. — Symptoms on the part of this organ are rare. Enlargement
is occasionlly detected. Jaundice is a very rare complication. It may be
either of a catarrhal nature or due to parenchymatous changes. It was
present in only Tl per cent of the ^lunicli autopsies. Abscess of the
liver is a very rare sequela.
Respiratory System. — Episfaxis is an early symptom in many cases,
and precedes typhoid fever more commonly than it does any other febrile
affection. It is occasionally profuse and serious.
Lanjngitis is not very common. The nlcers and the perichondritis
have already been described. (Edema apart from nlceration is rare. In
this country the laryngeal complications of typhoid fever seem much less
frequent than on the Continent. I have seen ulcers in only four or five
instances, and twice only perichondritis, both of which cases recovered,
one after the expectoration of large portions of the thyroid cartilage.
Bronchitis is one of the most frequent initial symptoms. It is indi-
cated by the presence of numerous piping rales. It may come on with great
severity, and in a case at the Philadelphia Hospital I regard 3d for several
days the bronchial catarrh as the primary affection. The smaller tubes
may be involved, producing urgent cough and even slight cyanosis. Col-
lapse and lobular pneumonia may also occur.
Lobar j^iicumonia is met with under two conditions :
24 SPECIFIC INFECTIOUS DISEASES.
1. It may be the initial symptom of the disease. After an indisposition
of a day or so, the patient is seized with a chill, has high fever, pain in
the side, and within forty-eight hours there are signs of consolidation, and
the evidences of an ordinary lobar pneumonia. The intestinal symptoms
may not develop until toward the end of the first week or later ; the pul-
monary symptoms persist, crisis does not occur ; the aspect of the patient
changes, and by the end of the second week the clinical picture is that of
typhoid fever. Spots may then be present and doubts as to the nature of
the case are solved. In other instances, in the absence of a characteristic
eruption the case remains dubious, and it is impossible to say whether
the disease has been pneumonia, in which the so-called typhoid symp-
toms have developed, or whether it was typhoid fever with early im-
plication of the lungs. Whether this condition depends upon the pneu-
mococcus or is the result of an early localization of the typhoid bacillus
has not yet been settled. I have twice performed autopsies in cases of
this pneumo-typhus^ as it is called by the French and Germans, and can
speak positively of its onset with all the symptoms of a frank pneumonia.
2. Lobar pneumonia forms a serious and by no means infrequent
complication of the second or third week. It was present in over 8 per
cent of the Munich cases and occurred in nine of my cases. The symp-
toms are usually not marked There may be no rusty sputa, and, unless
sought for, the condition is frequently overlooked. Infarction, abscess
and gangrene are occasional pulmonary complications.
Hypostatic congestion of the lungs and oedema, due to enfeebled circu-
lation in the later periods of the disease, are very common. The physical
signs are defective resonance at the bases, feeble breath-sounds, and, on
deep inspiration, moist rales. Pleurisy is by no means an uncommon
complication. It was present in about 8 per cent of the Munich autop-
sies. It may develop slowly in convalescence, in which case it is almost
always purulent. Another occasional pulmonary complication is hcemopty-
sis, which I once saw at the height of the disease. After death, no lesions
of the lungs or bronchi were discovered. Miliary tuberculosis occasionally
develops, and some writers hold that there is a greater susceptibility to
infection with the tubercle bacillus after this than after otlicr fevers.
Nervous System. — As already noted, the disease may set in witli in-
tense and persisting headache or an aggravated form of neuralgia. There
are cases in which the effect of the poison is manifested on the nervous
system early and with the greatest intensity. There are headache, photo-
phobia, retraction of the neck, marked twitching of the muscles, rigidity,
and even convulsions. In such cases tlie diagnosis of meningitis is in-
variably made. I have examined post mortem three such cases, in two of
which the diagnosis of cerebro-spinal fever had been made. In not one of
them was there any trace of meningeal inflammation, only the most in-
tense congestion of the cerebral and spinal pia. Meningitis, however, may
occur, but is extremely rare, as shown by the Munich record, in which
TVI'llolh KKVKU. 25
ihvvv were only clcvri) ainoii^^ tin* two tlioiiHiiii<l rtiHon. tSl4>k«tH'M didum
tliiit '' I line is no niii^^^lo iirrvoiiM Myrii)itorii wliiih riwiy not uimI doeii not
()('(nir iiKlrpciHlriitly of any iip|in'cijiljlc lusiijii of llic liniin, iitTVeNf or
H]>injil cord,'' is too oftni forj^'oltcri.
/ic/iriinii is piTsnit in all srNcrc chmch. It in (•(•rtuinly Ii'hh frequiTit
iiiidri- a I'ii'it! |»l;iii nf liy(lrnili('ra|iy. Il may \>r pn-Kofit from the outM^t,
hut usually docs not dcvclo)) until tlic second and HoiiictitiicH not until the
tliird week. It nuiy l)e sli;4ht and only nocturnal. It is, an a ruh*, a (juiet
delirium, lliou^di thero are cases in which the patient is very noisy and
constantly tries to f^ct out of hed, and, uidess carefully watched, may
escape. The patient does not often become maniacal. In heavy drinkcTH
the delirium may have tho character of dcliiium tremens. Kven in eaxeH
which have no positive delirium, the mental processes are usually dulleil
and the ])atient is listless and apathetic. In severe ca.ses the ]>atient pa.«.seH
into a condition of unconsciousness. The eyes may be open, hut he is ob-
livious to all BurrouTidin<; circumstances and lU'itluT knows nor can iiuli-
cato his wants. The mine and fa-ces are j)assed involuntarily. In this
})seudo-wakeful state, or coma vii^il as it is called, the eyes are open and
the patient is constantly muttering. The lips and tongue are tremulous;
there is twitcliing of the fingers and wrists — subsultus tendinum and
carphologia. Jle })ieks at the bedclothes or grasps at invisible objects.
These are among the most serious symptoms of the disease, and always
indicate danger.
Among important complications and sequelae are several nervous af-
fections. The para J i/ses are due in the majority of instances to neuritis.
It may be of a paraplegic type, or may involve only one or two nerves.
Occasionally, as in a case reported by George Ross,* all four limbs are
alfected.
Possibly some of these cases are due to poliomyelitis, not to neuritis.
This affection does not always follow, but may come on at the height of
the disease, as in a case recently under my care, in which during the
second week neuritis developed in both arms. Among other sequences
may be mentioned aphasia, which is more apt to occur in young children,
and great slowness of speech, which may or may not be associated with
mental weakness.
Post-febrile iusauiti/ is perhaps more frequent after typhoid than after
any other disease. Wood regards it as confusional insanity, the result of
impaired nutrition and exhaustion of the nervous centres. Five cases
have come under my observation, in four of which recovery took place.
Disturbances of the organs of the special senses are rare. Otitis media
occasionally develops. Ocular symptoms are uncommon.
Renal System. — Retention of urine is an early symptom in many
* Paralysis in Typhoid Fever. Transactions of the Association of American Physi-
cians, vol. iii.
26 SPECIFIC INFECTIOUS DISEASES.
cases, and is more frequent in some epidemics than in others. The nrine
is usually diminished at first, has the ordinary febrile characters, and the
pigments are increased. Later in the disease it is more abundant and
lighter in color.
Ehrlich has described a reaction, which he believes is rarely met with
except in typhoid fever. This so-called diazo-reaction is produced as fol-
lows: Two solutions are employed, kept in separate bottles: one con-
taining a saturated solution of sulphanilic acid in a solution of hydro-
chloric acid (50 c. c. to 1,000 c. c.) ; the other a ^ per cent solution of
sodium nitrite. To make the test, a few cubic centimetres of urine are
placed in a small test-tube with an equal quantity of a mixture of solution
of the sulphanilic acid (40 c. c.) and the sodium nitrite (1 c. c), the whole
being thoroughly shaken. One cubic centimetre of ammonia is then
allowed to flow carefully down the side of the tube, forming a colorless
zone above the yellow urine, and at the junction of the two a deep brown-
ish-red ring will be seen if the reaction is present. AVith normal urine a
lighter brownish ring is produced, without a shade of red. The color of
the foam of the mixed urine and reagent, and the tint they produce when
largely diluted with water, are characteristic, being in both cases of a deli-
cate rose-red if the diazo-reaction be present ; but if not, brownish-
yellow.
In twenty-six cases at my clinic, Simon found the reaction in twenty-
two. It may be present previous to the occurrence of the rash, and as late
as the twenty-second day. The value of the test is lessened by its occur-
rence in cases of miliary tuberculosis, and occasionally in the acute dis-
eases associated with high fever.
The renal complications in typhoid fever may be thus grouped :
{a) Febrile albuminuria, which is very common and of no special sig-
nificance ; thus, in the first seventy-five cases admitted to the Johns Hop.
kins Hospital, albumen was present in forty-six, and in twenty-five cases
casts were also found. In only two of these cases were there indications
of an acute B right's disease.
{h) Acute nephritis occurring at the onset or during the height of the
disease — the nepliro-typlius of the Germans, the fievre typho'ide a forme
renale of the French — may set in, with all the symptoms of the most in-
tense Bright's disease, masking in many instances the true nature of the
malady. After an indisposition of a few days there may be fever, pain in
the back, and the passage of a small amount of bloody urine. In a recent
case * the early symptoms were all those of the most severe nephritis, and
death occurred on tlie fourteenth day from perforation of the bowel. In
other instances, as in a case reported in the same paper, the nephritis sets
in at the end of the first or during the second week, and may modify con-
* Acute Nephritis in Typhoid Fever. Johns Hopkins Hospital Reports, February,
1800.
TVI'llnlh ri'lVKK. 27
Hi(l('ni))lv 111*' cli.'ir.'U'lcr nf iIk- tli-iaM-, aii<i rsrn rtri<l«T tin* «h;i;'ri«»-iM
(loitl)! fill.
((•) 'I'Ih- iKpliriiis nf ( (»ii\ali>.rii('r. 'I'liin in moro ('oniriion hut Ivfn
scrioiiM. Il (l('\r|(i|iM afii-r tlir fall nf tiit) fovor, niid JH UHiiiilly iixH^K.'iiiUMl
with (I'dcniu. It (IncM iKd prosoiit cliHriictcrH dilTrrciit from i\w (inliimry
poHt-fci)!'!!*' iicpliritiM.
(</) TIh' i«'iMarkiil>l(» lymplmrnatniis ncjtliritis (Icscnhrd hy ]•". \Va;^MMT
and olIuTs, and already ndcrri'd to in tlio Hcction on inorljid aniitoiny, pro-
duces, as li v\\]{\ no synjptoniH.
(/■) l\ist-fiiitln)i(i pt/r/ifis. — In this ilir pelves of the kidney and tho
eali('(\s are jit first covered with a nicinhianoiis exudation, but erosion and
uh'cration may suhse(|uently occiii-. 'I'hrro may l)c hlood and pus in the
urine. This condition occurred in tliri'C of my cases, in one of whidi it
was associaliMl witli extensive membranous inlhunmation of tlie bladder.
Sim})Ie eatarrli of the bladder is rare.
Orchitis is occasionally niet with durin<( convalescence. Sadrain col-
lected sixteen cases in the literature. It is usually associated with a
catarrhal urethritis. Induration or atrophy nuiy occur, and more rarely
su})puration.
Osseous System. — A multiple arthritis occasionally occurs; more com-
monly it is limited to a single joint, and nuiy pass on to su})j)uration.
Spontaneous luxation may develop. Necrosis is not uncommon during
convalescence. Keen collected thirty-seven cases after typhoid fever. It
is probably always the result of a secondary infection. Its most usual
seat is the tibia.
The )}fusrh'f( sliow in some cases the degeneration already referred to,
but it does not cause any symptoms. Iliemorrhage occasionally occurs
into the muscles, and late in the disease abscess may develop.
Association of other Diseases. — Erysipelas is a rare complica-
tion, most commonly met with during convalescence. In 1,420 cases at
Basle it occurred ten times. Griesinger states that it is met with in "2
per cent.
Measles may develop during the fever or in convalescence. Chicken-
pox and noma have been reported in children. Pseudo-membranous in-
Hammations may occur in the pharynx, larynx, or genitals. ^lalarial and
typlioid fevers may be associated, but a majority of the cases of so-called
typho-malarial fever are either remittent or true typhoid.
Varieties of Typhoid. — Typhoid fever is an extremely complex
disease. ^lany forms have been described, some of which present exag-
geration of common symptoms, others modification in the course, others
again greater intensity of action on certain organs. As we have seen,
when the nervous system is specially involved, it has been called the
cerebro-spinal form ; when the kidneys are early and severely affected,
nephro-typhoid ; when the disease begins with pulmonary symptoms,
pneumo-typhoid ; when the disease is characterized throughout by profuse
28 SPECIFIC INFECTIOUS DISEASES.
sweats, the sudoral form of the disease. It is a mistake, 1 think, to rec-
oornize or speak of these as varieties. It is enough to remember that
typhoid may set in occasionally with symptoms localised in certain organs,
and that many of its symptoms are extremely inconstant — in one epidemic
uniform and text-book-like, in another slight or not met with. This di-
versified symptomatology has led to many clinical errors, and in the ab-
sence of the salutary lessons of morbid anatomy it is not surprising that
practitioners have so often been led astray. We may recognize, with
Murchison, the following varieties :
1. The mild and abort ive forms. It is very important for the practi-
tioner to recognize the mild type of typhoid fever, often spoken of as
gastric fever or even regarded as simple febricula. In this form, the
typhus levissirnus of Griesinger, the symptoms are similar in kind but
altogether less intense than in the graver attacks, although the onset may
be sudden and severe. The temperature rarely reaches 103°, and the
fever of onset may not show the gradual ascending evening record. The
spleen is enlarged, the rose-spots may be marked ; often they are very
few in number. The diarrhoea is variable, sometimes it is not present.
In such cases the symptoms may persist for from sixteen to twenty
days.
In the abortive form the symptoms of onset may be marked with shiv-
ering and fever of 103° or even higher. The date of onset is often defi-
nite, a point upon which Jiirgensen lays great stress. Rose-spots may occur
from the second to the fifth day. Early in the second week or at the end
of the first week the fever falls, often with profuse sweating, and conva-
lescence is established. In this abortive form relapse may occur and may
occasionally prove severe. When typhoid fever prevails extensively these
cases are not uncommon. I agree with J. C. Wilson, who states that they
are not nearly so common in this country as in Europe.
2. The grave form is usually characterized by high fever and pro-
nounced nervous symptoms. In this category, too, come the very severe
cases setting in with pneumonia and Bright's disease, and with the very
intense gastro-intestinal or cerebro-spinal symptoms.
3. The latent or amhidatory form of typhoid fever, which is particu-
larly common in hospital practice. The symptoms are often very slight,
and the patient scarcely feels ill enough to go to bed. He has languor,
perhaps slight diarrhoea, but keeps about and may even attend to his work
throughout the entire attack. In other instances delirium sets in. The
worst cases of this form are seen in sailors, who keep uj) and about, though
feeling ill and feverish. When brought to the hospital they often develop
symptoms of a most severe type of the disease. Haemorrhage or perfora-
tion may be the first symptom of this ambulatory type. Sir W. Jenner
has called attention to the dangers of this form, and particularly to the
grave prognosis in the case of persons who have travelled far with the dis-
ease in progress.
•rvnioii) FKVKK. 29
'I'hcn^ in u raro and fatal fmni c.f typlioni ffvcr, (.•Imra^jUTiixti wy
outancnuM and imicniis lia'nn»rrlia^'<-H.
An (tfvhnlc typlioid frvtr in nM<»;;ni/.rd l»y uuthorM. liiclMTrnoiMtfr wivi
(hat iIh* ('as(*H W(«ro not uncoiMnioii at Baxlu. The palienU prcM'iiU'fl
lassitude, d(|ii( ssinii, hcadajdn', fnrrrd lon^juc, Iohh al apiM'tiU;, hIow j»u1m%
and even tilt' spots and cnlar^i'd splmi. I havf in» {KTHonal knowledge <>f
such cases.
Typhoid Fev«r in Children. Mpistaxis rarely occurs; the rine in
tenipcraluie is less ;,M"a<lual ; the initial hroncliial catarrh in often oh-
Hcrved. The iumvous syinptorns aic nfieii prominent; there arc wukcfnl-
lu'ss and deliiiiini ; diarrlnea is often ah.-eiit. The ijinh may 1k» very Hli^dit,
but tho nH)st copious eruption 1 have ever seen was in a (ddld of ei^'ht.
(hldly enough, considering the readiness with which the lymph (dementi*
of tho inti'stine in (diildrcn are involved, the ahdonnnal symptoms are
slii^ht. Fatal Ineniorrhage and perforation are rare. Among the secjuela*,
aphasia and bone lesions may be mentioned as more common in children
than in adidts. The mortality of tv])hoid fever in (diildren is low. Forch-
lieimer, in the Cincinnati epidemic in 1888, treated seventy cases without
a death.
Typhoid Fever in the Aged. — After the fortieth year the disease runs
a less favorable course, and the mortality is very high. Of sixty-four
fatal cases, seven were over forty years of age ; one was aged sixty-three,
another seventy. The fever is not so high, but complications are more
common, jiarticularly pneumonia and heart failure.
Relapse. — Helapses vary in frequency in different epidemics, and, it
appears, in different places. The percentages of ditTcrent authors range
from 3 per cent (Murchison), 11 per cent (Biiumler) to 15 or 18 per cent
(Immerniann). In Wagner's clinic, from 188*-3 to 188G, there were 49
relapses in 5G1 cases. F. C. Shattuck reports 21 relapses in 129 cases.
R. L. MacDonnell 1 relapse in 100 cases. A relapse is a repetition,
sometimes only a summary, of the original attack. Von Zicmssen in-
sists correctly that two of the three important symptoms— step-like tem-
perature at onset, roseola, and enlarged spleen — should be present to de-
termine the diagnosis of a relapse. The intestinal lesions are repeated,
though with less intensity and regularity. It is to be carefully distin-
guished from the fever of convalescence — or recrudescence — which has
already been described. This is usually transitory, not lasting longer
than a day or two. There are occasional instances in which the fever
lasts for four or five days without rose-spots, or without enlargement of
the spleen, and it may be impossible to determine whether there has been
a relapse or not. The true relapse usually sets in after complete deferves-
cence. Irvine noted the average duration of the interval in his cases
at a little over five days. In eleven of Shattuck's cases the relapse
began before complete defervescence. The onset is nsually abrupt,
though the step-like ascent is sometimes well seen, as in Chart I. The
30 SPECIFIC INFECTIOUS DISEASES.
eruption may be seen as early as the third or fourth day. The attack
is usually less severe and of shorter duration. Of Murchison's fifty-three
cases the mean duration of the first attack was about twenty-six, of the
interval eleven, of the relajise fifteen days. The mortality of the relapse is
not high. The relapse may be repeated, and a third and fourth relapse
may occur.
The relapse is a reinfection from within, but we are still quite ignorant
of the conditions favoring its occurrence. It is not at all likely that any
special methods of treatment favor the relapse, though hydrotherapy has
labored under this reproach.
Diagnosis. — If the patient is seen from the outset there is rarely any
difficulty in diagnosing typhoid fever of typical course. In the prefebrile
period the headache, weakness, loss of appetite and epistaxis are extremely
suggestive, and, with an ascending pyrexia, scarcely need the distinctive
rash to clinch the diagnosis.
The early and intense localisation of the symptoms in certain organs is
a frequent source of error in diagnosis.
Cases coming on with severe headache, photophobia, delirium, twitch-
ingf of the muscles and retraction of the head are almost invariablv
regarded as cerebro-spinal meningitis. Under such circumstances it may
for a few days be impossible to make a satisfactory diagnosis. I have
thrice performed autopsies on cases of this kind in which no suspicion of
tvphoid fever had been present; the intense cerebro-spinal manifestations
having dominated the scene. Until the appearance of abdominal symp-
toms or the rash, it may be quite impossible to determine the nature of
the case. Cerebro-spinal meningitis is, however, a rare disease ; typhoid
fever a very common one, and the onset with severe nervous symptoms is
by no means infrequent. Fully one half of the cases of the so-called brain-
fever belong to this category.
I have already spoken of the misleading pulmonary symptoms, which
occasionally develop at the very outset of the disease. The bronchitis
rarely causes error, though it may be intense and attract the chief at-
tention. More difficult are the cases setting in with chill and followed
rapidly by pneumonia. I have brought such a case before the class
one week as typical pneumonia, and a fortnight later shown the same
case as undoubtedly one of typlioid fever. In another case, in which the
onset was with definite pneumonia, no spots developed, and, though there
were diarrhoea, meteorism, and the most pronounced nervous symptoms,
the doubt still remains whether it was a case of typhoid fever or one of
pneumonia in wliich severe secondary symptoms developed. Tliere is
less danger of mistaking tlie pneumonia which develops at the height of
the disease, and yet this is possible, as in a case admitted a few months
ago to my wards — a man aged seventy, insensible, witli a dry tongue,
tremor, ecchymoses upon the wrists and ankles, no rose-spots, enlarge-
ment of the spleen, and consolidation of his right lower lobe. It was very
'rNI'llolD KKVKIt. 3]
ijjitiinil, i»:irliiiiljirly ninco (Ihto wum ho luHtory, to n-j^'unl Hiirh a com* bm
8iMiil(^ piirtiiiioMiti with proroiiiiil cniiHlitutioiml (liHttirlmiict% but the uiu
topsy hIiowciI the chaniclrriHlir N-kIoiih of typhoi<l frvi-r.
Id riiularial ic;^noiiH typhoid ami rt'iiiiltriit ft?V(TH an? vrry fn-rpiciitly
coMfoimdcil. I coiifrMM myself iiiial)l<' to difTrrcntiiitc^ rcrt4ii?i cawn of nia-
hirial rfinitlciil I'loiii typhoid fi'vrr, without the \)\(kh\ cxiiniirmtion. I
have r(-|)ral('dly, l)oth in iMiihi(h'lplna and Uiiltitiion^ Kciit vhm'h to the
wui'ds as typhoid fi'vcr wliicli sid)S('(pi('iitiy proved to \)v ordinary inahirial
reriiitle!it. 'IMie |)atieiit comes with a Idstory of ;//^//^//.v^, weakiiesH, diar-
riuea, perhaps vomitini,^ ; the loii^nie is furred and white, the chcckH are
flushed, the spleen is sliL,ditIy eidari,'ed, temperaturo 102" or 10.'J°. 'i'hcTc
may inch'ed he (h'liriiini, and the clinical j»ictni-e of the early stage of typhoid
fover may he complete. On at, least two occasions I have shown siudi
cases to my class as typhoid fever, and several times patients have heen
sent to the wards with instructions to have the head shaved and to he^in
the bat lis. The oidy safeguard ai^ainst error is the exaniiiuition of the
blood, which should be done systenuitically in regions in which malaria
l>revails. The presence of Laveran's organisms is distinctive and abso-
lutely diagnostic.
Acute miliary tuberculosis is not infrequently mistaken for typhoid
fever. The })oints in ditTerential diagnosis will be discussed under that
disease. Tuberculous peritonitis in certain of its forms may closely simu-
late typhoid fever.
Puncture of the spleen for the purpose of obtaining cultures is justifi-
able only in exceptional circumstances.
Prognosis. — The mortality ranges from 10 to 30 per cent. Of the
enormous number of deaths analyzed by Murchison, the mortality was
nearly 19 per cent. The death-rate at the Montreal General Hospital,
for twenty years, was 11 "2 per cent. In recent years the mortality in
typhoid fever has certainly diminished, and, nnder the influence of Brand,
the reintroduction of hydrotherapy has reduced the mortality in institu-
tions in a remarkable manner, even as low as 5 or G per cent. Especially
unfavorable sym]>toms are high fever, delirium with toxic symptoms,
luvmorrhage — though by some this is not thought very unfavorable — and
peritonitis.
Si(d(Ie?i Death. — It is difficult in many cases to explain this most lam-
entable of accidents in the disease. There are cases in which neither
cerebral, renal, nor cardiac changes have been found, and instances too in
which it does not seem likely that there could have been a special localisa-
tion of the toxic poisons in the pnenmogastric centres. McPhedran, in
reporting a case of the kind, in which the post-mortem showed no ade-
quate cause of death, suggests that the experiments of McWilliams on
sudden cardiac failure probably explain the occurrence of death in cer-
tain of these cases in which neither embolism nor uremia is present.
Under conditions of abnormal nutrition there is sometimes induced a state
32 SPECIFIC INFECTIOUS DISEASES.
of delirium cordis^ which may develop spontaneously, or, in the case of
animals, on slight irritation of the heart, with the result of extreme irreg-
ularity and finally failure of action. It occurs more frequently in men
than in women, according to Dewevre's statistics, in a proportion of 114
to 2G. It may occur at the height of the fever, and, as pointed out by
Graves, may also happen during convalescence.
Fat subjects stand typhoid fever badly. The mortality in women is
greater than in men. The complications and dangers are more serious in
the ambulatory form in which the patient has kept about for a week or ten
days. Early involvement of the nervous system is a bad indication ; and
the low, muttering delirium with tremor means a close fight for life. Prog-
nostic signs from the fever alone are deceptive. A temperature above 104°
may be well borne for many days if the nervous system is not involved.
Prophylaxis. — In cities the prevalence of typhoid fever is directly
proportionate to the inefficiency of the drainage and the water-supply.
There is no truer indication of the sanitary condition of a town than the
returns of the number of cases of this disease. With the improvement in
drainage the mortality in many cities has been reduced one half or even
more. One of the most striking instances is afforded by the city of Munich.
Von Ziemssen has published charts illustrating the extraordinary reduc-
tion in the prevalence of typhoid fever since the completion of the drain-
age system of that city. The average yearly number of admissions to
hospital of cases of t3^phoid fever was, between the years 1866 and 1880,
594, while from 1881 to 1888 inclusive, the average has been only about
100. During this same period the typhoid mortality of the whole city
presented a yearly average of 208, but from 1881 to 1888 the yearly
average was only 40.
By most rigid methods of disinfection much may be done to prevent
the spread of the infection.
The following procedures, suggested by Fitz, should be carried out in
hospital practice, and, with modifications, in private houses :
1. " Mattresses and pillows (when liable to become soiled) are to be
protected by close-fitting rubber covers.
2. " Bed and body linen are to be changed daily. Bed-spreads, blank-
ets, rubber sheets and rubber covers are to be changed at once when soiled.
Avoid shaking any of the articles.
3. " All changed linens, bath-towels, rubber slieets and covers are to
be immediately wrapped in a sheet soaked in carbolic acid (one to forty).
Kemove them to the rinse-house as soon as possible, and soak six hours in
carbolic acid (one to forty). Then boil the linen for a half-hour, and wash
witli soft soap. Tlie rubber slieets and covers are to be rinsed in cold
water, dried, and aired for eight hours. The bed-spreads and blankets
are to be aired eight hours daily.
4. " Feeding-utensils, immediately after using, are to be thoroughly
cleansed in boiling water.
'^^ ni<»!i) I'liVKit. ^3
T). " DcjcctioiiH an* t<» !•(• hummvimI into u lu'd-jmti ronUiinin;^ half a
pint of carliolic acid (mir to twenty). The naU'rt iiri^ to Im* clciiiiMiMl with
paper, and afterward with a compn'SM doth wet with carholif! a''i(l (ont; to
forty).
tl. '^ Add two (piartM of ('ar))oli(MU'id (ono to twenty), in (lividcMl jKir-
tions, to the cniilciits of the l»i'd-pan ; mix tli(>rou;^hly hy Hliukin^ and
throw the li(|iiid into the liopju-r. 'I'ho h(Mi-pan and hopper are to \)0
cleansed with carholic aiMd (ono to twenty) and wiped dry. 'I'lie cloth
nsed for the al)oV(» purpose i.s to he at once hnrned.
7. "Tiie cor])ao is to he covered with a sheet wet with carholic acid
(one to foity).
S. *' After tlie discharr^e of the patient from the lio.«pital, the mat-
tresses arc to i)e aired every day for a week, 'i'he hedstead is to be washed
with corro.sive suhlimate (one to one thousand).
1). "These directions are to he followed until the patient is free from
fever.''
When epidemics are prevalent tlie drinking-water and the milk used
in families should he boiled. These precautions should be taken also by
recent residents in any locality, and it is much safer for travellers to drink
li^lit wines or mineral water rather than ordinary water or milk.
Treatment. — (^0 General Management— 'J'he profession was lone:
in learniuLC ihiit typhoid fever is not a disease to be treated by medicines.
Careful nursing and a regulated diet are the essentials in a majority of the
cases. The patient should be in a well-ventilated room (or in summer
out of doors during the day), strictly confined to bed from the outset, and
there remain until convalescence is well established. The bed sliould be
single, not too high, and the mattress sliould not be too hard. The woven
wire bed, with soft hair mattress, upon which are two folds of blanket,
combines the two great qualities of a sick-bed, smoothness and elasticity.
A rubber cloth should be placed under the sheet. An intelligent nurse
should be in charge. When this is impossible, the attending physician
should write out specific instructions regarding diet, treatment of the dis-
charges, and the bed-linen.
(I)) Diet, — Those forms of food should be given which are digested
with the greatest ease, and which leave behind the smallest amount of resi-
due to form fieces. Milk is the most suitable food. If used alone, three
pints at least may be given to an adult in twenty-four hours, always diluted
with water, lime-water, or aerated waters. Partially peptonized milk, when
not distasteful to the patient, is occasionally serviceable. The stools of a
patient on a strictly milk diet should be examined from time to time, to see
if the milk is entirely digested. Fever patients often receive more than
they can utilize, in which case masses of curds are seen in the stools, or
microscopically fat-corpuscles in extraordinary abundance. Under these
circumstances it is best to substitute, for part of the milk, mutton or
chicken broths, or beef -juice, or a clear consomme, all of which mav be made
31 SPECIFIC INFECTIOUS DISEASES.
very palatable by the addition of fresh vegetable juices. Some patients
will take whey or buttermilk when the ordinary milk is distasteful. Thin
barley-gruel, well strained, is an excellent food for typhoid-fever patients.
Eggs may be given, either beaten up in milk or, better still, in the form of
albumen-water. This is prepared by straining the whites of eggs through
a cloth and mixing them with an equal quantity of water. It may be
flavored with lemon, and, if the patient is taking spirits, whisky or brandy
is very conveniently given with this. Patients who are unable to take milk
can subsist for a time on this alone.
The patient should be encouraged to drink water freely, which may be
pleasantly cold. Iced tea, barley-water, or lemonade may also be given,
and there is no objection to coffee or cocoa in moderate quantities. Fruits
are not, as a rule, allowable, though the juice of lemon or orange may
be given. Typhoid patients should be fed at stated intervals through
the day. At night it depends upon the general condition of the patient
whether he should be aroused from sleep, or not. In mild cases it is
not well to disturb the patient. When there is stupor, however, the
patient should be roused for food at the regular intervals night and day.
Alcohol is not necessary in all cases, but may be given when the weak-
ness is marked, the fever high, and the pulse failing. In young healthy
adults, without nervous symptoms and without very high fever, alcohol is
not required ; but in any case, when the heart-beat is feeble and the first
sound becomes obscure, if there is a muttering delirium, subsultus tendi-
num and a dry tongue, brandy or whisky should be freely given. In such
a case from eight to twelve ounces of brandy in the twenty- four hours is a
moderate amount.
(c) Treatment of the Fever. — The persistent pyrexia is in itself a
danger, but perhaps not the chief danger. Cases with high fever alone,
without delirium or signs of involvement of the nervous system, are not
nearly so serious as those cases in which, with a temperature of 104°, there
are pronounced nervous symptoms. For the fever and its concomitants
there is no treatment so efficacious as that by cold water, introduced at
the end of the last century by Currie, of Liverpool, and of late years
forced upon the profession by Brand, of Stettin. In institutions a rigid
system of hydrotherapy should be carried out. At my clinic the follow-
ing plan is followed : Every third hour, if the temperature is above 102*5°,
the patient is placed in a bath (at 70° Fahr.), which is wheeled to the bed-
side. In this he remains from fifteen to twenty minutes, and is then
taken out, wrapped in a dry slieet and covered with a light blanket.
Enough water is used to cover the patient's body to the neck. The head
is sponged during the bjith, and, if there is much torpor, cold water is
poured over it from a height of a foot or two. The rectal temperature is
taken immediately after the bath, and again three quarters of an hour
later. The patient often complains bitterly when in the bath, and shiver-
ing and blueness are almost a constant sequence. Food is usually given
•rvi'iioiD ii:vi:i:
85
with a Htiinnlnrjt iiftcr lln« luu li. 'I'lir «»nly rrintni-itKlicntiofiH firo (HTito-
nitiH iukI li:i<iii(M'rliii;^'(\ NcitluM' broiicliitiH nor piiniiiioniii tin* mo n'^iinl-
<•(!. It is nol ncccMsjirv t«» n'lu'W the wntrr in tin* liutli niorr Uian oiico in
lIu' Iwi'iity-foiir Ikuiim. 'I'Iu' ju;(!()rn|mnyinj; churl -Ik.u^ flu- numlxT of
Ni>.
.//iviu«^>t^ Admitted
//.
Ward
/
Jtltli'tA
n
Tomp
100
lOR
107
100
lOA
104
m
iw
101
1001
09
«8
VI
96
Tomp-
Pulse
Resp.
Stools
Urine
Day of
Disease.
:*;)?4A\f..:.jA**.J.w.J?^...i.J>*Jl».J.M?.M*.ji^^
|6
1|
18
«l
19
I I I
Chart V.
baths and the influence on the fever during two days of treatment. The
good etfoots of the baths are: (1) the reduction of the fever: ('2) the in-
tellect becomes clearer, the stu})or lessens, and the muscular twitchings
disappear; (3) a general tonic action, particularly on the heart; (4) in-
somnia is lessened, the patient usually falling asleep for two or three hours
after each bath: and (5), most important of all, the mortality is, under
this plan of treatment, reduced to a minimum. This rigid method is not,
however, without serious drawbacks, and personally I sympathize with
those who designate it as entirely barbarous. To transfer a patient from
a warm bed to a tub at 70° Fahr., and to keep him there twenty minutes
or longer in spite of his piteous entreaties, does seem harsh treatment ; and
the subsequent shivering and blueness look distressing. A majority of our
patients complain of it bitterly, and in private practice it is scarcely feasible.
The convincing statistics of the Brand method, as it is called, have
36 SPECIFIC INFECTIOUS DISEASES.
long been before the profession ; but so far they have made but little im-
pression in English-speaking communities. Cayley, of London, has been
a warm advocate, but the rigid treatment is not often carried out in Eng-
lish or American institutions. J. C. Wilson, of Philadelphia, and Baruch,
of New York, have pleaded for its general introduction into our hospitals.
Among the most striking figures are those recently published by Hare,
from the Brisbane Hospital, Australia. Under the expectant plan, 1,838
cases — mortality, 14*8 per cent; incomplete bath treatment, 171 cases —
mortality, 12-3 per cent ; strict bath treatment, 797 cases — mortality, 7 per
cent.
The lukewarm bath, gradually cooled, is much more satisfactory in
private practice. A bath at from 90° to 80°, and cooled down 10° or 12°
by pouring cold water on the patient, will be found very satisfactory.
When an insuperable objection to the bath exists, other hydr ©therapeutic
measures may be taken. The body may be sponged with tepid or cold
water every time the temperature rises above 102*5°. If done thoroughly,
taking limb by limb first, and then the trunk, occupying from twenty
minutes to half an hour in the process, the rectal temperature may be re-
duced two or even three degrees. In private practice, when the bath is
not available, the cold-pack is a good substitute. The patient is wrapped
in a sheet wrung out of water at 60° or 65°, and cold water is sprinkled
over him with an ordinary watering-pot. This is very efficacious in cases
with pronounced nervous symptoms.
Medicinal antipyretics are rarely indicated. Quinine, which was em-
ployed so much in former years, has a slight though positive action, but
its use has very wisely been restricted. The same may be said of the
nK)re recent antipyretics. Personally, I abandoned their employment
some years ago. If given, antifebrin is the most suitable in doses of from
four to eight grains. The action is prompt, and it is less depressing than
antipyrin.
(d) Antiseptic Medication. — Very laudable endeavors have been made
in many quarters to introduce methods of treatment directed toward the
destruction of the typhoid bacilli, or the toxic agent which they produce,
but so far without success. Good results have been claimed from the car-
bolic and iodine treatment. Others advocate corrosive sublimate or calo-
mel, )8-iuiphthol, and the salicin preparations. I can testify to the ineffi-
ciency of the carbolic acid and iodine and of the /?-naphthol. With the
mercurial preparations I have no experience. Fortunately for the patients,
a majority of these medicines meet one of the two objects which Hip-
pocrates says the physician should always have in view — they do no harm.
Recently Burney Yeo has advocated the use of chlorine water and quinine
as having a marked antiseptic action.
{(') Treatment of the Special Symptoms.— The abdominal pain and
tympanites are best treated by fomentations or turpentine stupes. The
latter, if well ap])lied, give great relief. Sir William Jenner, at his clinic,
'IN ri loll) FKVKIC. 87
used to liiy /^rnit Htn^sH on tiir ailviiiita^^'H of ii wcll-ap|ili<'il iiir|Hiiiiit(r
Kliipc. lie (lin'clcMl it to Im' applird us fdllowK: A tlun?M'l mllrr wum plty-i'd
lu'iiculli tlx* pnlinit, ami tlicri a liiMildi; layer of tliiii llaiincif wriiii^' out of
hot \vat('r, wiili a fcvs ili-i»|)s of turpcntiiK* Hprinklcd upon it, wuh applied
to the altdoiiini ainl cnvricd \sitli (lie cikIm of the I'olh'r.
'\'\n' nir/mrisni is u dillicnlt and distrt'HHing H)'rnj»tom to treat. When
thi^ ^a.s is ill the lar^«' howel, a tiii)e may he juixsed or ii tnirpeiitiiie enernu
tjiveii. l''or tyinpaiiites, willi a dry toii^nie, turpentine wan ext^-nwively
used hv the (►liter huhlin physicians, and it wan introdueed into thirt <'ountrv
hy the late(ieor;'e H. Wo<m1. I'nfortunatelv it is of very little Bcrviee in the
soveror eases, ^vhieh too ofieii resist all treatment. 'I'he routine adminis-
tration of liii|t('iitiiie in all eases of typhoid fever is a useless pructicc, for
tlu» pei-petiKilion of which, in this ^^'eni'ration, H. C Wood is lar^'ely re-
sponsihle. Slokcs protested airainst it in his day, and very truly said that
its use should be limited to the later periods of the disease, when it may
sometimes be used with advantage, as (iraves directs, in dnichm doses
every six houis. Sometimes, if beef-juice and albumen-water are substi-
tuted for milk, the distention lessens. Charcoal, bismuth, and )3-naphthol
may be tried.
For the duirvluva^ if severe — that is, if there are more than three or
four stools daily — a starch and oi)ium enema may be given ; or, by the
mouth, a combination of bismuth, in large doses, with Dover's powder; or
the acid diarrhiea mixture, acetate of lead (grs. 2), dilute acetic acid
(in, 15-20), and acetate of morphia (gr. J-J). The stools should be ex-
amined to see that the diarrhani is not aggravated by the presence of
curds.
Constipation is present in many cases, and, thougli I liave never seen it
do harm, yet it is well every third or fourth day to give an ordinary
enema. I have never used the initial dose of calomel, which is so highly
recommended by some practitioners. If a laxative is needed during the
course of the disease, the Ilunyadi-janos or Friedriclishall water may be
given.
Hannorrhage from the bowels is best treated with full doses of acetate
of lead and opium. As absolute rest is essential, the greatest care should
be taken in the use of the bed-pan. It is perhaps better to allow the
patient to pass the motions into the draw sheet. Ice may be freely given,
and the amount of food should be restricted for eight or ten hours. If
there is a tendency to collapse, stimulants should be given and, if necessary,
hypodermic injections of ether. The patient may be spared the usual
styptic mixtures with which he is so often drenched. Turpentine is
warmly recommended by certain authors.
Peritonitis. — In a majority of the cases this is an inevitably fatal
complication. The only hope lies in restriction of the inflammation.
Cases have unquestionably recovered. Morphia should be given sub-
cutaneously. If the peritonitis be due to perforation, the question of
38 SPECIFIC INFPXTIOUS DISEASES.
laparotomy may be discussed. If perforation has occurred in the second
or third week, it would be useless under the circumstances to attempt to
stitch a slit in the intestine ; if, on the other hand, it occurs during con-
valescence, it is only right to give the patient a chance, and the operation
should be performed.
Progressive lieart-failure is one of the most frequent and perhaps one
of the most serious of the conditions which the physician has to combat.
As in other specific affections, this is in part due to the prolonged action
of the fever and in part is a toxic effect. Alcohol is here our mainstay
and can be given freely. Str3'chnine is most useful and may be given
hypodermically in full doses. Whether digitalis is indicated in the failing
heart of fevers is not yet settled. Personally, I am by no means convinced
that it does good. Hypodermic injections of ether may be resorted to, and
are sometimes helpful in tiding the patient over a critical period.
The nervous symptoms of typhoid fever are best treated by hydro-
tlierapy. One special advantage of this plan is., that the restlessness is
allayed, the delirium quieted, and sedatives are rarely needed. In the
cases which set in early with severe headache, meningeal symptoms and
high fever, the cold bath, or in private practice the cold-pack, should be
employed. An ice-cap may be placed on the head, and if necessary mor-
phia administered hypodermically. The practice, in such cases, of apply-
ing blisters to the nape of the neck and to the extremities is, to paraphrase
Huxham's words, an iinivliolesome severity^ which should long ago have
been discarded by the profession. For the nocturnal restlessness, so dis-
tressing in some cases, Dover's powder should be given. As a rule, if a
hypnotic is indicated, it is best to give opium in some form. Pulmonary
complications should, if severe, receive appropriate treatment.
In protracted cases ver}^ special care should be taken to guard against
bed-sores. Absolute cleanliness and careful drying of the parts after an
evacuation should be enjoined. The patient should be turned from side to
side and propped with pillows, and the back can then be sponged with
spirits. On the first appearance of a sore, the water or air bed should be
used.
(/) The Management of Convalescence.— With the fall of the tem-
perature to normal in the evening, and the disappearance of the other
symptoms, the patient enters upon a stage which is often more difficult to
manage than the attack itself. Convalescents from typhoid fever frequently
cause greater anxiety than patients in the attack. The question of food
has to be met at once, as the patient develops a ravenous appetite and
clamors for a fuller diet. My custom has been not to allow solid food
until the temperature has been normal for ten days. This is, I think, a
safe rule, leaning perhaps to the side of extreme caution ; but after all
with eggs, milk toast, milk puddings, and jellies, the patient can take a
fairly varied diet. Many leading practitioners allow solid food to a
patient so soon as he desires it. Peabody gives it on the disajipearance of
'IVninlD l-KVKIC. 39
(lie f(\(i-, lli(^ Into AiiHtiii l«'liii( wiiH aUd in favor of ^'ivin^ Holiil foo<l
early; and Naimyn, at llir ShuHhiir;; MiMlical ('Iiiii<*, told iiii- timt tliiii
was his practice. I had iiii early le.sson in this matter which I have never
for«j;otteii. A \<nin;( la«l iti the Montreal (ient-ral lIoHpital, in wliow euMj
1 Was niiich interested, passed tlimn;;!! a tnlerahly nharp attack of typlioid
fever. Two weeks afli-r the evmin;^ ternp<'nitiire had l»e«-n normal, and
only a (lay oi" two hefore his inteiKh-d dis(dnirp', In? ut« HC'VtTai mutton
chops, and within twenty-four hourH wan in u state of eollapHo frr)ni per-
foration. A small transvers(» rent was fouiul at the l>ott<im of an ulcer
which was in process of healin;.^. it is not easy to Kuy why Holid fcxxl,
particularly uu-ats, sijould disa^n-ee, but in so many instu?iet'8 an indiHcrc-
tion in diet is followed hy slii^ht fever, the so-culled fvhris carnisy tluit it
is in the best interests of the patient to restrict the diet for some time
after the fever has fallen. An indiscretion in diet may indeed precipitate
a relapse. 'Plu» patient may he allowed to sit up fora short time about tlie
end of the lirst week of convalescence, and the })eriod may be prolon;:ed
with a <::radual return of strenj^th. He should move about slowly, and
when tlu^ weather is favorable should be in the open air as much as
possible. The patient should be guarded at this period against all un-
necessary excitement. Emotional disturbance not infrecpiently is the
cause of a recrudescence of the fever. Constipation is not uncommon in
convalescence and is best treated by enemata. A protracted diarrha'u,
which is usually due to ulceration in the colon, may retard recovery. In
such cases the diet should be restricted to milk, and the patient should
be confined to bed ; large doses of bismuth and astringent injections will
prove useful.
The recrudescence of the fever does not require special treatment.
The treatment of the relapse is essentially that of the original attack.
Among the dangers of convalescence may be mentioned tuberculosis,
which is said by Murchison to be more common after this than after any
other fever. There are facts in the literature favoring this view, but it is
a rare sequence in this country.
II. TYPHUS FEVER.
Definition. — An acute infectious disease characterised by sudden
onset, a maculated rash, marked nervous symptoms, and a termination,
usually by crisis, about the end of the second week.
Etiology. — The disease has long been known under the names of
hospital fever, spotted fever, jail fever, camp fever, and ship fever. In
Germany it is known as exantliematic typhus, in contradistinction to
abdominal typhus.
Typhus is now a rare disease. Sporadic cases occur from time to time
in the large centres of population, but epidemics are infrequent. In this
4
40 SPECIFIC INFECTIOUS DISEASES.
country during the past ten years there have been very few outbreaks. In
New York in 1881-'82 seven hundred and thirty-five cases were admitted
into the Riverside Hospital ; in Philadelphia a small epidemic occurred
in 1883 at the Philadelphia Hospital.
The special elements in the etiology of typhus are overcrowding and
poverty. As Hirsch tersely puts it, " Die Geschichte des Typhus ist die
des menschlichen Elends." Overcrowding, lack of cleanliness, intem-
perance and bad food are predisposing causes. The disease still lurks in
the worst quarters of London and Glasgow, and is seen occasionally in
New York and Philadelphia. It is more common in Great Britain and
Ireland than in other parts of Europe. Murchison held that the disease
might originate spontaneously under favorable conditions. This opinion
is suggested by the occurrence of local outbreaks under circumstances
vv^hich render it difficult to explain its importation, but the analogy of
other infectious diseases is directly against it. In 1877 there occurred a
local outbreak of typhus at the House of Refuge, in Montreal, in which
city the disease had not existed for many years. The overcrowding was
so great in the basement-rooms of the refuge that at night there were not
more than eighty-eight cubic feet of space to each person. Eleven per-
sons were affected. It was not possible to trace the source of infection.
Typhus is one of the most highly contagious of febrile affections. In
epidemics nurses and doctors in attendance upon the sick are almost inva-
riably attacked. There is no disease which has so many victims in the
profession. In the extensive epidemic in the early and middle part of this
century many hundred physicians died in the discharge of their duty.
Casual attendance upon cases in limited epidemics does not appear to be
very risky, but when cases are aggregated together in wards the poison
appears concentrated and the danger of infection is much enhanced.
Bedding and clothes retain the poison for a long time.
The microbe of typhus fever has not yet been determined. Illava
found in twenty of thirty-three bodies, and twice during life, a strepto-ba-
cillus, the relation of which to the disease has not yet been determined.
Morbid Anatomy. — The anatomical changes are those which result
from intense fever. The blood is dark and fluid, the muscles are of a deep
red color and often show a granular degeneration, particularly in the
heart; the liver is enlarged and soft and may have a dull clay-like lustre;
the kidneys are swollen ; there is moderate enlargement of the spleen, and
a general hyperplasia of the lymph-follicles. Peyer's glands are not ulcer-
ated. Bronchial catarrh is usually, and hypostatic congestion of the lungs
often, present. The skin shows the petechial rash.
Symptoms. — Incubation. — This is placed at about twelve days, but
it may bo less. Tliere may be ill-defined feelings of discomfort. As a rule,
however, the invasion is abrupt and marked by chills or a single rigor,
followed by fever. The chills may recur during the first few days, and
there is headache with pains in the back and legs. There is early pros-
rVIMIIS I'KVKK. 41
tnition, 1111)1 ilir |i;iliriit in ^linl Id lake In \\\h Ix'd at oiirv. TIm* ti'iiiju'ru*
tiir(> is iii;;h nl lirst, iind iiiny ill tain itn niiixiiiiiiiii on the m'coiid or third
(lav. Tlic |)iils(< is full, rapid, and not ho frr«|ncntly di<Toti(' um in tv|>)ioi(l.
'V\iv ton^iu* is fiirii'd and wl»it»>, and tlirn* is an early trnd»;ncy to drv-
nosH. Tlu' face is HiisImmI, the ('Vcm an; con^rMti'd, ilir cxjircHMioii in dull
iiiid Hlupiii. NniiiiiiiiL^ may in* a distri'HHin^ Hyinptoiii. In Hoverc; cumch
nuMilal syiiiploms aic present, frnm the outset, cithrr a tnild fi'hrile delir-
iiiin or an cxeitc)!, active, alnmst rnaniaeal condition. lironchiiil catarrh
is eoininoii.
Sta^O 1)1' Kruptioil.— l-'roni the third to thu lifth day the eruption ap-
pears tirst upnii the ahdonu-n and upj>er part of tin? chest, and then
iij)()n the exti-emiiies and face; developin<r so rapidly that in two or
throo (lays it is all nut. Tliei-c are two elements in the ei-iij)ti(>n : a nuh-
cuticular m()ttlini,% "a line, invi^ndar, dusky red niottlin|(, as if helow
the surface of the skin some little distance, and seen throu^^h u semi-
ojuique medium" (Buiduman); and distinct })a])ular rose-s])ot8 which
change to petechiie. In some instances the petechial rash comes out
with the rose-spots. Collie describes the rash as consisting of three parts
— rose-colored spots wliich disappear on })ressure, dark-red spots which
are modified by pressure, and petechiiL' upon which ])ressure produces
no elTect. In children the rash at lirst may ])resent a striking resem-
blance to measles, and give as a wliole a curiously mottled apj)earance to
the skin. The term mulberry rash is sometimes ai)plied to it. In mild
cases the eruption is slight, but even then is largely petechial in character.
As the rash is largely hj^morrhagic, it is permanent and does not disappear
after deatli. Usually the skin is dry, so that sudaminal vesicles are not
common. It is stated by some authors that a distinctive odor is present.
During the second week the general symptoms are usually much aggra-
vated. The prostration becomes more marked, the delirium more intense,
and the fever rises. The patient lies on his back with a dull expressionless
face, flushed cheeks, injected conjunctivae, and contracted pupils. The
pulse increases in frequency and is feebler, the face is dusky, and the
condition becomes more serious. Retention of urine is common. Coma-
vigil is frequent, a condition in which the patient lies with open eyes, but
quite unconscious. Subsultus tendinum and picking at the bedclothes
are frequently seen. The tongue is dry, brown, and cracked, and there are
sordes on the teeth. Respiration is accelerated, the heart's action becomes
more and more enfeebled, and death takes place from exhaustion. In
favorable cases, about the end of the second w^ek occurs the crisis, in
which, often after a deep sleep, the patient awakes feeling much better
and with a clear mind. The temperature falls, and although the prostra-
tion may be extreme, convalescence is rapid and relapse very rare. This
abrupt termination by crisis is in striking contrast to the mode of termi-
nation in typhoid fever.
Fever. — The temperature rises steadily durins: the firet four or five
42 SPECIFIC INFECTIOUS DISEASES.
days, and the morning remissions are not marked. The maximum tem-
perature is usually reached by the fifth day, when the temperature may
reach 105°, 10G°, or 107°. In mild cases it seldom rises above 103°.
After reaching its maximum the temperature generally continues with
slight morning remissions until the twelfth or fourteenth day, when the
crisis occurs, during which the temperature may fall below normal with-
in twelve or twenty-four hours. Preceding a fatal termination, there is
usually a rapid rise in the fever to 108° or even 109°.
The heart may early show signs of weakness. The first sound becomes
feeble and almost inaudible, and a systolic murmur at the apex is not in-
frequent. Hypostatic congestion of the lungs occurs in all severe cases.
The brain symptoms are usually more pronounced than in typhoid,
and the delirium is more constant.
The urine in typhus shows the usual febrile increase of urea and uric
acid. The chlorides diminish or disappear. Albumen is present in a
large proportion of the cases, but nephritis seldom occurs.
Variations in the course of the disease are naturally common. There
are malignant cases which rapidly prove fatal within two or three days ;
the so-called typhus siderans. On the other hand, during epidemics there
are extremely mild cases in which the fever is slight, the delirium absent,
and convalescence is established by the tenth day.
Complications and Sequelae. — Broncho-pneumonia is perhaps
the most common complication. It may pass on to gangrene. In certain
epidemics gangrene of the toes, the hands, or the nose, and in children
noma or cancrum oris, have occurred. Meningitis is rare. Paralyses,
which are probably due to the post-febrile neuritis, are not very uncommon.
Septic processes, such as parotitis and abscesses in the subcutaneous tissues
and in the joints, are occasionally met. Nephritis is rare. Haematemesis
may occur.
Prognosis. — The mortality ranges in different epidemics from 12 to
20 per cent. It is very slight in the young. Children, who are quite as
frequently attacked as adults, rarely die. After middle age the mortality
is high, in some epidemics 50 per cent. Death usually occurs toward the
close of the second week and is due to the toxaemia. In the third week
it is more commonly due to pneumonia.
Diagnosis. — During an epidemic there is rarely any doubt, for tlie
disease presents distinctive general characters. Isolated cases may be very
difficult to distinguish from typhoid fever. While in typical instances
the eruption in the two affections is very different, yet taken alone it may
be deceptive, since in typhoid fever a roseolous rash may be abundant and
there is occasionally a subcuticular mottling and even petechiae. The
difference in the onset, particularly in the temperature, is marked ; but
cases in which it is important to make an accurate diagnosis are not usu-
ally seen until the fourth or fifth day. The suddenness of the onset, the
greater frequency of the chill, and the early prostration are the distinctive
TV I'll IS I'KVKK. 43
fcHliiics in tvplniM. Tin' hriiiii HyiiijitnmH too iiro cfirlittr. It Im CHHy to
put down on paper cliilMinilc (iilTrrmtial iliHtinctioriM, which an; prur-
tii-ally UHch'SH at (lie hcdsich', parliculurly wlini i\\ti «lim'a>M? in not pn*-
vaiiin;^ as an cpidrtnic. In spitradic casrM th«> dia^'iioMiH iri »uirn<rtirn(*M
(>\l I'cnirlv dilliciilt. I hav(^ M-m Miin-hison liini.^rlf in <h)iiht, and iii(;ri;
than oiicf I li:i\r known a dia^^niosis to he d«'f«'rn*d until tho Mrr/i'o rada-
iwris. SuvcMV crrchro-spinal fever may closely ninndate typhuH at the out-
set, hut the dia«^n()sis is usually clear within a few days. Mali^'iiant vari-
ola also has certain features in c(»ininon with sevenj typhus, hut tin?
greater extent (»f the ha'inorrha<^es and the hleeding from the nuirouH
inonihranes make the dia|::nosis clear within a short time. 'J'he rasli at
tirst resemhles that of measles, hut in tins disease; tlu? eruption is hrighter
rod in color, often crescent ic or irregular in arrangement, and a])pears
lirst in the face.
'I'hc frecjuency with which other diseases are mistaken for typhus is
shown hy the fact that during and following the e})idemic of 1881 in New
York one hundred and eiglit cases were wrongly diagnosed — one eighth
of t]u> entire numher — aiul sent to tlie Kiverside Hospital (K. W. ('lia])in).
Treatment. — Practically tlie general management of the disease is
like tliat of typlu)id fever. Hydrotherapy should he thoroughly and sys-
tematically em})loyed. Judging from the good results which we have
ohtained by this method in typhoid cases with nervous sym})toms much
may be expected from it. Certain authorities have spoken against it, but
it should be given a more extended trial. Medicinal antipyretics are less
suitable than in typhoid, as the tendency to heart-weakness is often more
pronounced. As a rule the patients require from the outset a supporting
treatment; water should be freely given, and alcohol in suitable doses
according to the condition of the pulse.
The bowels may be kept open by mild aperients. The so-called spe-
cific medication, by sulphocarbolates, the sulphides, carbolic acid, etc., is
not commended by those who have had the largest experience. The spe-
cial nervous symptoms and the pulmonary symptoms should be dealt with
as in typhoid fever. In epidemics, when the conditions of the climate
are suitable, the cases are best treated in tents in the open air.
HI. RELAPSING FEVER {Fehris recurrens).
Definition. — A specific infectious disease caused by the spirochjste
(spirillum) of Obermeier, characterised by definite febrile paroxysms which
usually last six days and are followed by a remission of about the same
length of time, then by a second paroxysm, which may be repeated three
or even four times, whence the name relapsing fever.
Etiology. — This disease, which has also the names "famine fever"
and " seven-day fever," has been known since the early part of the
44r SPECIFIC INFECTIOUS DISEASES.
eighteenth century, and has from time to time extensively prevailed in
Europe and in Ireland. It is common in India, where the conditions for
its development seem always to be present. The subject has been spe-
cially studied by Vandyke Carter, of Bombay. It was first seen in this
country in 1844, when cases were admitted to the Philadelphia Hospital,
which are described by Meredith Clymer in his work on fevers. Flint saw
cases in 1850-'51. In 1869 it prevailed extensively in epidemic form in
New York and Philadelphia; since then it has not appeared.
The special conditions under which it develops are very similar to
those of tyj^hus fever. Overcrowding and deficient food are the condi-
tions which seem to promote the rapid spread of the virus. Neither age,
sex, nor season seems to have any special influence. It is a contagious
disease and may be communicated from person to person, but is not so
contagious as typhus. Murchison thinks it may be transported by fomites.
One attack does not confer immunity from subsequent attacks. In 18T3
Obermeier described an organism in the blood which is now recognised
as the specific agent. This spirillum, or more correctly spirocha^te, is
from three to six times the length of the diameter of a red blood-cor-
puscle, and forms a narrow spiral filament which is readily seen moving
among the red corpuscles during a paroxysm. They are present in the
blood only during the fever. Shortly before the crisis and in the inter-
vals they are not found, though small glistening bodies, which are stated
to be their spores, appear in the blood. The disease has been produced
in human beings by inoculation of the blood during the paroxysm. It
has also been produced in monkeys. Nothing is yet known with refer-
ence to the life history of the spirochgete.
Morbid Anatomy. — There are no characteristic anatomical appear-
ances in relapsing fever. If death takes place during the paroxysm the
spleen is large and soft, and the liver, kidneys and heart show cloudy
swelling. There may be infarcts in the kidneys and spleen. The bone
marrow has been found in a condition of hyperplasia. Ecchymoses are
not uncommon.
Symptoms. — Incuhation appears to be short, and in some instances
the attack develops promptly after exposure ; more frequently, however,
from five to seven days elapse.
The invasion is abrupt, with chill, fever, and intense pain in the back
and limbs. In young persons there may be nausea, vomiting, and convul-
sions. The temperature rises rapidly and may reach 104° on the evening
of the first day. Sweats are common. The pulse is rapid, ranging from
110 to 130. There may be delirium if the fever is high. Swelling of the
spleen can be detected early. Jaundice is common in some epidemics.
The gastric symptoms may be severe. There are seldom intestinal symp-
toms. Cough may be present. Occasionally herpes is noted, and there
may be miliary vesicles and petechijE. During the paroxysm the blood
invariably shows the spirochoete. After persisting with severity or even
Ui:L\rsiN(i FKVKU.
45
willi Mil iiiiiTiiHiM^' iMlcii.sity f«'r \\\v or nix jIjivh llu* rriniH (irciirx. In tho
(Mmisc i*\' a frw lioiirs, iiccompiiiiitMl liy prnfiiKtj MNVriitin^', hoim-liiiu'M by
(linrrlura, I he icm|M<nitiin' falls to iiornml (»r fvi-ii Muliiioriiml, and tho
|)('rio(l nf jipvri'xiji hc^'ins.
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H 'I III II I ' 11 II I'l IC 1. IK I I 'II •!
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Chart VT. — Uolnpsing fever (Murchison).
Tho crisis may occur as early as tlie tliinl day, or it may be tlehiyed to
the tenth ; it usually comes, however, about the end of the first week.
In delicate and elderly persons there may be collapse. Tlie convalescence
is rapid, and in a few days the patient is up and about. Then in a week,
usually on tlie fourteenth day, he again has a rigor, or a series of chills ;
the fever returns and the attuck is repeated. A second crisis occurs from
the twentieth to the twenty-third day, and again the patient recovers
rapidly. As a rule the relapse is shorter than the original attack. A
second and a third may occur, and there are instances on record of even a
fourth and a fifth. In epidemics there are cases terminating by crisis on
the seventh or eighth day without the occurrence of relapse. In pro-
tracted cases the convalescence is very tedious, as the patient is much
exhausted.
Relapsing fever is not a very fatal disease. Murchison states that the
mortality is about 4 per cent. In the enfeebled and old, death may occur
at the height of the original attack.
Complications are not frequent. In some epidemics nephritis and
hn?maturia have occurred. Pneumonia appears to be frequent and may
interrupt tlie typical course of the disease. The acute enlargement of the
spleen may end in rupture, and the haemorrhage from the stomach which
has been met with occasionally is probably associated with this enlarge-
ment. Post-febrile paralyses may occur. Ophthalmia has followed cer-
tain epidemics, and may prove a very tedious and serious complication.
Jaundice has already been mentioned. In pregnant women abortion usu-
ally takes place.
46 SPECIFIC INFECTIOUS DISEASES.
Diagnosis. — The onset and general symptoms may not at first be
distinctive. At the beginning of an epidemic the cases are usually
regarded as anomalous typhoid ; but once the typical course is followed
in a case tlie diagnosis is clear. The blood examination, which should be
made in all doubtful cases of fever, affords a definite criterion by which
the diagnosis can readily be made.
Treatment. — The paroxysm can neither be cut short nor its recur-
rence prevented It might be thought that quinine, with its powerful ac-
tion, would certainly meet the indications, but it does not seem to have the
slightest influence. The disease must be treated like any other continued
fever by careful nursing, a regular diet, and ordinary hygienic measures.
Of special symptoms, pains in the back and in the limbs and joints demand
opium. In enfeebled persons the collapse at the crisis may be serious, and
stimulants with ammonia and digitalis should be given freely.
IV. SMALL-POX (Variola).
Definition. — An acute infectious disease characterised by an erup-
tion which passes through the stages of papule, vesicle, pustule and
crust. The mucous membranes in contact with the air may also be
affected. Severe cases may be complicated with cutaneous and visceral
haemorrhages.
Etiology. — It has not yet been determined in what country small-
pox originated. The disease is said to have existed in China many centu-
ries before Christ. The j!?e5/a magna described by Galen (and of which
Marcus Aurelius died) is believed to be small-pox. In the sixth century
it prevailed, and subsequently, at the time of the Crusades, became wide-
spread. It was brought to America by the Spaniards early in the sixteenth
century. The first accurate account was given by Rliazes, an Arabian phy-
sician who lived in the ninth century, and whose admirable description is
available in Greenhill's translation for the Sydenham Society. In the
seventeenth century a thorough study of the disease was made by the illus-
trious Sydenham, who still remains one of the most trustworthy authori-
ties on the subject.
Special events in the history of the disease are the introduction of
inoculation into Europe, by Lady Mary Wortley Montagu, in 1718, and
the discovery of vaccination by Jenner, in 1798.
Small-pox is one of the most virulent of contagious diseases, and per-
sons exposed, if unprotected by vaccination, are almost invariably attacked.
There are instances on record of persons insusceptible to the disease. It
is said that Diemerbrock, a celebrated Utrecht professor in the seventeenth
century, was not only himself exempt, but likewise many members of his
family. One of the nurses in the small-pox department of the Montreal
(Jeneral Hospital stated that she had never been successfully vaccinated.
SMAI.L-I'OX. 17
iiiid H\\i<i ccrhiiMly \uu\ no nmrk. Siidi lUMtancrH, liowrvrr, of niitiirul im-
rimnity arc vciv nin*.
Afft'. Sin:ill-|M)\ in cntniiioii at all u^^^m, but in purticuliirly fulul to
y()mi«( cliildrrti ; thus, in Ihc Mmitrcul (•piilriiii(! of 1 HH/), Hl{ (M)r cent of
tlu' (leal lis well' (if ('liil(lr«ii iimlrr tni y<MirH of a^c. TImj fulit/t in niero
mav 1)0 attackcil, Imt mily if tin- mntlin- luTsolf in the Hiibjoct of the? (iin-
iMisi>. Tho cliild may ho honi with the rash out or with tho Hcarx, Mon-
coinniouly the fo'lus is not alTcrtcil, and children horn in a Hrnall-f)ox hos-
pital, if vaccinated iiinnediat«'ly, nuiy escape the disease; usually, howe\er,
tiloy die i-aily.
iScX. — Males and females are e(|iially alTected.
/utrr. — Amoti^ abori^dnal races Hmall-])()x is terribly fatal. Wlien
tho disease was lirst introduced into America the Mtixieans died by
thousands, and the North American Indians liavc also been frequjmtly
decimated by this plague. It is stated that the negro is especially sus-
ceptible.
77/^ Co)if(((/iinn develops in the system ()f tlie small-j)ox patient and
is reproduced in the pustules. It exists in the secretions and excretions,
and in the exhalations from the lungs and the skin. 'J'he dried scales con-
stitute by far the most important element, and as a dust-like powder are
distributed everywhere in the room during convalescence, becoming at-
tached to clothing and various articles of furniture. The disease is proba-
bly contagious from a very early stage, though I think it hiis not yet been
determined whether the contagion is active before the eruption develops.
The poison is of unnsual tenacity and clings to infected localities. It is
convevod bv persons who have been in contact with the sick and by fomites.
During epidemics it is no doubt widely spread in street-cars and public con-
veyances. It must not be forgotten that an unprotected person may con-
tract a very virulent form of the disease from the mild varioloid.
The disease smoulders here and there in different localities, and when
conditions are favorable becomes epidemic. Perhaps the most remarkable
instance in modern times of the rapid extension of the disease occurred in
Montreal in 1885. Small-pox had been prevalent in that city between
1870 and 1875, when it died out, in part owing to the exhaustion of suit-
able material and in part owing to the introduction of animal vaccination.
The health reports show that the city was free from the disease until 1885.
During these years vaccination, to which many of the French Canadians
are opposed, was much neglected, so that a large unprotected population
grew up in the city. On February *'38th a Pullman-car conductor, who had
travelled from Chicago, where the disease had been slightly prevalent, was
admitted into the Hotel-Dieu, the civic small-pox hospital being at the
time closed. Isolation was not carried out, and on the 1st of April a serv-
ant in the hospital died of small-pox. Following her decease, with a neg-
ligence absolutely criminal, the authorities of the hospital dismissed all
patients presenting no symptoms of contagion, who could go home. The
48 SPECIFIC INFECTIOUS DISEASES.
disease spread like fire in dry grass, and within nine months there died in
the city, of small-pox, 3,164 persons.
The nature of the contagion of small-pox is still unknown. Weigert
and others have described micro-organisms in the pock, but they are the
ordinary pus cocci, and the part which they play in the affection is by
no means certain. Still less definite are the observations on the occur-
rence of sporozoa in the pocks. It is not a little remarkable that in a
disease which is rightly regarded as the type of all infectious maladies,
the specific virus still remains unknown.
Morbid Anatomy. — A section of a papule as it is passing into the
vesicular stage shows in the rete mucosum^ close to the true skin, an area
in which the cells are smooth, granular, and do not take the staining fluid.
This represents a focus of coagulation-necrosis due, according to Weigert,
to the presence of micrococci. Around this area there is active inflamma-
tory reaction, and in the vesicular stage the rete mucosum presents re-
ticuli, or spaces, which contain serum, leucocytes and fibrin filaments. The
central depression or umbilication corresponds to the area of primary
necrosis. In the stage of maturation the reticular spaces become filled
with leucocytes and many of the cells of the rete mucosum become vesicu-
lar. The papillae of the true skin below the pustule are swollen and infil-
trated with embryonic cells to a variable degree. If the suppuration ex-
tends into this layer, scarring inevitably results; but if it is confined to the
upper layer, it does not necessarily follow. In the haemorrhagic cases,
red corpuscles pass out in large numbers from the vessels and occupy the
vesicular spaces. They infiltrate also the deeper layers of the epidermis
in the skin adjacent to the papules. Frequently a hair- follicle passes
through the centre of a papule.
In the mouth the pustules may be seen upon the tongue and the buccal
mucosa, and on the palate. The eruption may be abundant also in the
pharynx and the upper part of the oesophagus. In exceptionally rare
cases the eruption extends down the oesophagus and even into the stom-
ach. Swelling of the Peyer's follicles is not uncommon ; the pustules
have been seen in the rectum.
In the larynx the eruption may be associated with a fibrinous exudate
and sometimes with oedema. Occasionally the inflammation passes deeply
and involves the cartilages. In the trachea and bronchi there may be
ulcerative erosions, but true pocks, such as are seen on the skin, do not
occur. There are no special lesions of the lungs, but congestion and bron-
cho-pneumonia are very common. The liver is sometimes fatty. A diffuse
hepatitis, associated with intense congestion of the vessels and migration
of the leucocytes, has been described ; Weigert has noted small areas of
necrosis.
There is nothing special in the condition of the blood, and even in the
most malignant cases there are no microscopic alterations. In the blood-
drop, however, it will be seen that the corpuscles, instead of forming
SMALIi-PoX. 49
n)ul«MUix, a^^'n-j^'iih' t(»^rtlur in irrr;^Milar cliirnim. 'I'lir lirurt orru^ioimlly
shows iiivocjudiul clmn^^i'H, |»an'ruliMiiiiioiiM iiikI futty ; i'ii«l<><iir«l»liM aii<l
|M'ri<'iir(lilis nrc luicoiiimoii. I-'ii'IkIi wrilris lm\«' (IrnrrilH'd an riHliirliTiliH
of till' coroimry vt'sscls in coniUM'tion with hmijiII-jiox. '!'hi5 M))leen m murk-
4'(lly t'lihiri^ctl. A|i;nl fi<»m the cloiuly HWciliu^ and art'iiH of <'oa>(uhil ion-
net rosiH, Irsions of ihc ki(lni<y.s aro not coininon. N«'phritiH n my occur
tluiin«^ convah'sci'iico. (liiMri has called attention to the frc'ineney of
orchitis in this disease, 'riicre are scattered areas of necrosis with cell in-
liltration.
In tlic hainorrhairiir form extravasations are fonnd on the HerotiH and
mucous surfaces, in the pnrciu'liyma of orpins, in tlie connective titwucH,
and about the ncrvc-shcatlis. In one instance 1 found the entire retro-
peritoneal tissue inliltrated with a lar;^'e coa;;ulum, and there were also ex-
tensivi» extravasations in the course of the thoracic aorta. IIa'nn)rrhage.s
in the hone-nuirrow have also been des<'ril)ed by (tolgi. There may be
li;vmorrha<^es into the muscles. ]*ontick has described the 8j)leen as very
tirm and hard in h;cnu>rrha<j:ic small-pox, and >nch was the case in seven
instances whicli I examined. The liver has been described as fatty in
these rapid cases, but in live of my seven cases it was of normal size,
dense, and tirm. In two it was large and fatty ; but one man had necro-
sis of the tibia, and the other was a drunkard. The ecchymoses are scat-
tered over the meninges of the brain and cord, and in one case there vrixs
a clot in the riirht ventricle. In five of the cases there were areas of haem-
orrhagio infarction of the lung. In four instances the pelves of the
kidney were blocked with dark clots, which extended into the calices and
down the •ureters. In one instance the coats of the bladder were uni-
forndy ha^norrhagic and not a trace of normal tissue could be seen. The
extravasations in the mucous membrane of the stomach and intestines
were numerous and large. Peyer's glands were swollen and prominent in
four instances.
Symptoms. — Three forms of small-pox are described :
1. Wiriola vera ; (a) Discrete, (b) Confluent.
2. Variola Invmorrhagica ; {a) Purpura variolosa or black small-pox ;
{!)) lIa?morrhagic pustular form, variola hiemorrhagiea pustulosa.
3. Varioloid^ or small-pox modified by vaccination.
1. Variola Vera. — The affection may be conveniently described under
various stages : {a) Incuhation. This is variously estimated at from seven
to twelve days, or even longer. I have seen it develop on the eighth day
after exposure to infection, and there are well-authenticated instances in
which the stage of incubation has been prolonged to twenty days. It is
unusual for patients to complain of any symptoms in this stage.
{b) Invasion. — In adults a chill and in children a convulsion are com-
mon initial symptoms. There may be repeated chills within the first
twenty-four hours. Intense frontal headache, severe lumbar pains and
vomiting are very constant features. The pains in the back and in the
60
SPECIFIC INFECTIOUS DISEASES.
limbs are more severe in the initial stage of this than of any other erup-
tive fever, and their combination with headache and vomiting is so sug-
9 10 11 12 13 14 15 16 i:
18
40 0°
39 O*
38-0°
3ro«
IBHHHBIIIIIIBIBHIHUB
wamm
IIIHIIIiH
Initial Fever Eruption.
Suppurative Fever.
Chart VII. — Tnie small-pox.
gestive that in epidemics precautionary measures may often be taken
several days before the eruption decides positively the nature of the dis-
ease. The temperature rises quickly, and may on the first day be 103°
or 104°. The pulse is rapid and full, not often dicrotic. In severe cases
there may be marked delirium, particularly if the fever is high. The
patient is restless and distressed, the face is flushed, and the eyes are
bright and clear. The skin is usually dry, though occasionally there are
profuse sweats. One cannot judge from these initial symptoms whether a
case is likely to be discrete or confluent, as the most intense backache and
fever may precede a very mild attack. Convulsions are not uncommon in
children.
In this stage of invasion the so-called initial rashes may occur, of
which two forms can be distinguished — the diffuse, scarlatinal, and the
macular or measly form ; either of which may be associated with petechiae
and occupy a variable extent of surface. In some instances they are gen-
eral, but as a rule they are limited, as pointed out by Simon, either to the
lower abdominal areas, to the inner surfaces of the thighs, and to the lat-
eral thoracic region or to the axillae. Occasionally they are found over
the extensor surfaces, particularly in the neighborhood of the knees and
elbows. These rashes, usually purpuric, are often associated with an
erythematous or erysipelatous blush. The scarlatinal rash may come out
as early as the second day and be as diffuse and vivid as in a true scarla-
tina. The measly rash may also be diffuse and identical in character with
that of measles. Urticaria is only occasionally seen. It was present once
in my Montreal cases. Apparently these initial rashes are more abundant
in some epidemics than in others; thus they were certainly more numerous
in the Montreal epidemics between 1870 and 1875 than they were in the
more extensive epidemic in 1885. They occur in from 10 to 16 per cent
SMALL pox. ft I
of ciiHCH. Ill the «Mim'H iifHlrr Miy run- in tlic Mfimll-pox dijuirt iiniil at tlio
Moiilrnil (inicnil il(>s)iilal lln' prn'mla^'r wjw l.'i.* Am will !>«; miiIihc-
((iiciilly riM'Mliniifd llir.m^ iiiiliiil niHlirM lmv«' <M»nHi<li'nil)l<' jliii^'rioHtiir vuliu*.
(r) /''rn/i/iii/i. (I) In I lie discnh' /'or///, iiHiially «»ii tlio fourth liuy,
Kinall hmI sjiols appear on tlir forrjirad, part icniarly at tlu? jiin(;tioii with
tlic hair, and mi the wriHtn. \N illiin llic lirHt twi'iity-foiir hourH from thrir
appearance tliey oeeur on (dlier parts of tin? face ami on tin* I'Xtn'initirH,
and a f(»vv are seen on the trunk. As the rash eorn«'H out the ternperatwrc
falls, the ^'(Mieral syniptonis snl)side, and the j)atient feeln eornfortahle. On
tile liflh or sixth day the papules ehan;^(» into vosicIeH with (•lour HurnmitH.
Kach one is elevated, eircidar, and presents ii little deprcHsion in the cen-
tre, th(» so-called uinhilieation. .Ahout the ei^dith day the; veHJclcs change
into pustuhvs, the und)ilieation disappears, tlu^ ilat top assunieH a ^lohular
form and hiu'oines grayish yellow in color, owin^ to th(^ contained pus.
There is an areola of injection ai)out the pustides and the skin between
them is swollen. 'This maturation first takes j)lace on the face, and follows
the order of tlu» appearance of the eruption, 'i'ho temperature now rises —
secondary fever — and the <j^eneral symptoms return. The swelling about
tlie pustules is attended with a ^ood deal of tension and })ain in the face ;
the eyelids become swollen and closed. In the discrete form the temj)er-
ature of maturation does not usually renuiin high for more than twenty-
four or twenty-six hours, so that on the tenth or eleventh day the fever
disappears and the stage of convalescence begins. The pustules rapidly
dry, first on the face and then on the other parts, and by the fourteenth or
fifteenth day desquamation may be far advanced on the face. There may
be in addition vesicles in the mouth, pharynx, and larynx, causing sore-
ness and swelling in these parts, with loss of voice. Whether pitting takes
place depends a good deal npon the severity of the disease. In a majority
of cases Sydenham's statement holds good, that " it is very rarely the case
that the distinct small-pox leaves its mark."
(2) Tlie Confluent Form. — With the same initial symptoms, though
usually of greater severity, the rash appears on the fourth, or, according to
Sydenham, on the third day. The more the eruption shows itself before
the fourth day, the more sure it is to become confluent (Sydenham). The
papules at first may be isolated and it is only later in the stage of matu-
ration that the eruption is confluent. But in severer cases the skin is
swollen and hypera?mic and the papules are very close together. On the
feet and hands, too, the papules are thickly set ; more scattered on the
limbs ; and quite discrete on the trunk. With the appearance of
the eruption the symptoms subside and the fever remits, but not to the
same extent as in the discrete form. Occasionally the temperature falls
to normal and the patient may be very comfortable. Then, usually on
the eighth day, the temperature again rises, the vesicles begin to change to
*The Initial Rashes of Small-pox. Canada Medical and Surgical Journal, 1875.
52 SPECIFIC INFECTIOUS DISEASES.
pustules, the hyperaemia about them becomes intense, the swelling of the
face and hands increases, and by the tenth day the pustules have fully
maturated, many of them have coalesced and the entire skin of the head
and extremities is a superficial abscess. The fever rises to 103° or 104°,
the pulse is from 110 to 120, and there is often delirium. As pointed out
by Sydenham, salivation in adults and diarrhoea in children are common
symptoms of this stage. There is usually much thirst. The eruption
may also be present in the mouth, and usually the pharynx and larynx are
involved and the voice is husky. Great swelling of the cervical lymphatic
glands occurs. At this stage the patient presents a terrible picture, un-
equalled in any other disease ; one which fully justifies the horror and
fright with which small-pox is associated in the public mind. Even when
the rash is confluent on the face, hands, and feet, the pustules remain
discrete on the trunk. The danger, as pointed out by Sydenham, is in
proportion to the number upon the face. " If upon the face they are as
thick as sand it is no advantage to have them few and far between on the
rest of the body." In fatal cases, by the tenth or eleventh day the pulse
gets feebler and more rapid, the delirium is marked, there is subsultus,
sometimes diarrhoea, and with these symptoms the patient dies. In other
instances between the eighth and eleventh day haemorrhagic symptoms
develop. When recovery takes place, the patient enters on the eleven tli
or twelfth day the period of —
(d) Desiccatio7i. — The pustules break and the pus exudes and forms
crusts. Throughout the third week the desiccation proceeds and in cases
of moderate severity the secondary fever subsides ; but in others it may
persist until the fourth week. The crusts in confluent small-pox adhere
for a long time and the process of scarring may take three or four weeks.
The crusts on the face fall oif, but the tough epidermis of the hands and
feet may be shed entire. We had in the small-pox department of the Mon-
treal General Hospital several moulds in epithelium of the hands and feet.
2. Hsemorrhagic small-pox occurs in two forms. In one the special
symptoms appear early and death follows in from two to six days. This
is the so-called petechial or black small-pox — purpura variolosa. In the
other form the case progresses as one of ordinary variola, and it is not
until the vesicular or pustular stage that hffimorrhage takes place into the
pocks or from the mucous membranes. This is sometimes called variola
hcBmorrhagica pustulosa.
Haemorrhagic small-pox is more common in some epidemics than in
others. It is less frequent in children than in adults. Of twenty-seven
cases admitted to the small-pox department of the Montreal General Hos-
pital there were three under ten years, four between fifteen and twenty,
nine between twenty and twenty-five, seven between twenty-five and thirty-
five, three between thirty-five and forty-five, and one above fifty. Young
and vigorous persons seem more liable to this form. Several of my cases
were above the average in muscular development. Men are more fre-
8M.\IJ- I'<'\
fi8
(jiictitiv alTccicd tliaii woiiirn ; thiiH in my lint there were twi-tity-oiio
iiiuli'M niul only nix fi'iimlrs. 'V\w iiilliimcr of varciniitioii Im hIiowii in the
fiict tliiit of tlie ciiKi'M foiirlcMiM wen? imvucciriutiMl, wliil<* u*>\ «.iii. «,f i)ii.
thir((M'ii who had scar.M had hreu revacciimtcd.
The cliiiiral rcaliircs of Hit- fnims of ha'iiiorrlja|(ic Hiiuill-pox are Hoine-
whal dilVf iciii.
In /inr/inr(( rariolosd llic ilhirss startH with i\w UHiuil Hyiiij)toniH, hut
with more intense constitutional disturhance. On th(^ evening of tlic
second or on the third day tliere is a dilTuse hy|»era*inic rash, j)urti(;ulurly
in tlio groins, with small puiictiforni lueinorrha^oH. The rush cxtendn,
becomes more distinctly h:cmorrlia;^M(', ami \\\r spotfl increaHe in Hize.
Ecehymoses appear on the conjunctiviv, and as early aH the third day
thcn^ may he Incmorrha^es from the mucous memhraiies. Death may
take place before the rash appears. 'Phis is truly a terribh? affection and
well developed cases present a frii:;htful appearance. 'Die skin may have
a uniforndy })urplish hue and the unfortunate victim may even look plum-
colored. The face is swollen and lar^e conjunctival hiemorrliages with
the deeply sunken cornea? give a ghastly appearance to the features.
The mind may renuiin clear to tlie end. Death occurs from the tliird
to the sixth day ; thus in thirteen of my cases deatli took place on or be-
fore this date. The earliest death was on the third day and there were
no traces of papules. There may be no mucous ha?morrhages ; thus in
one case of a most virulent character death occurred without bleeding
early on the fourth day. ILvmaturia is perhaps most common, next hae-
matemesis, and mehvna was noticed in a third of the cases. Metrorrhagia
was noticed in one only of the six females on my list. ILTmoptysis oc-
curred in five cases. The pulse in this form of small-pox is ra])id and
often hard and small. The respira-
tions are greatly increased in fre-
quency and out of all proportion to
the intensity of the fever. In the
case of a negro, whose respirations
the morning after admission were
32 and temperature 101°, after ex-
amining the lungs and finding noth-
ing to account for the increased
breathing, my suspicions were
aroused, and even on the dark skin
I was able on careful inspection to
detect haemorrhages in and about
the papules.
The annexed chart is from a
case of malignant small-pox which
came on abruptly on Thursday, October 24, 18T4. and which terminated
early on the fourth day. It shows the moderate temperature range.
Temp. ^•
104
IS
w
103
108
101
100
99
Day of
Disease.
Chart VIII. — HiTinorrhagic small-pox.
54 SPECIFIC INFECTIOUS DISEASES.
In variola pustiilosa hmmorrhagica the disease progresses as an ordi-
nary case of severe variola, and the haemorrhages do not develop until the
vesicular or pustular stage. The earlier the haemorrhage the greater is
the danger. There are undoubtedly instances of recovery when the bleed-
ing has taken place at the stage of maturation. Bleeding from the mu-
cous membranes is also common in this form, and the great majority of
the cases prove fatal, usually on the seventh, eighth, or ninth day.
There is a form of haemorrhagic small-pox in which bleeding takes
place into the pocks in the vesicular stage and is followed by a rapid
abortion of the rash and a speedy recovery. Six instances of this kind
came under my observation,* In four the haemorrhage took place on the
fourth day ; in two on the fifth day, just at the time of transition of the
papule into the vesicle. Extravasation takes place chiefly into the pocks
on the lower extremities and trunk, in only two instances occurring in
those of the arms. The eruption in all proved abortive, and no patients
under my care with an equal extent of eruption made such rapid recover-
ies. With these cases are to be grouped those in which the haemorrhages
occur in the pustules of the legs in patients who have in their delirium
got out of bed and wandered about. This modified form of haemorrhagic
small-pox is also described by Scheby-Buck.
3. Varioloid. — This term is applied to the modified form of small-pox
which affects persons who have been vaccinated. It may set in with
abruptness and severity, the temperature reaching 103°. More common-
ly it is in every respect milder in its initial symptoms, though the head-
ache and backache may be very distressing. The papules appear on the
evening of the third or on the fourth day. They are few in number and
may be confined to the face and hands. The fever drops at once and
the patient feels perfectly comfortable. The vesiculation and maturation
of the pocks take place rapidly and there is no secondary fever. There
is rarely any scarring. As a rule, when small-pox attacks a person who
has been vaccinated within five or six years the disease is mild, but there
are instances in which it is very severe, and it may even prove fatal.
There are several forms of rash ; thus in what has been known as horn-
pox, crystalline pox, and wart-pox the papules come out in numbers on
the third or fourth day, and by the fifth or sixth day have dried to a hard,
horny consistence.
Writers describe a variola sine er2(ptio7iey which is met with during
epidemics in young persons who have been well vaccinated, and who pre-
sent simply the initial symptoms of fever, headache and backache. In
a somewhat extensive experience in Montreal I do not remember to have
met with an instance of this kind or to have heard of one.
We do not now see the modified form of small-pox, resulting from
inoculation, in which by the seventh or eighth day a pustule forms at the
* Clinical Notes on Small-pox. Montreal, 1876.
HMALL roX. 55
ROJit of iiKMiilulioM ; llicn p-iunil fever Hctn ifi, ami with it, ulioiit thu
ulcvnitli tliiy, a /^^-luTal iTuplimi, uHuaily liiiiiu-d in «l«'^r<"r.
Complications. Considrrin^' tim wvc^rity of muiiy of the vum'H
Kiid thu gciinal rliaruchr of iIh* diHciuiis lUiKociutcd willi niiiltiplo
foci of Hiipitiiialidii, tl»o conipliciitionH in Hniall-pox urn roinurkubly
few.
liaivnj^itis is serious in threes ways : it may prodm-e a fatal <i'<l<nia <»f
the ^htltis; it is lial>h» to extend and invohe tiie <'artihi;^M'H, produrin^
ncHTosis ; and l>y diminishing th(^ Hensibility of tlie larynx, it allowH irri-
tating^' paiticlrs to reach the h»\sei- aii-passages, when; tjjey excite bron-
chitis or hroucho -pnciimoiiia.
Hronclio-pnenmonia is indeed one of the most common complications,
and is ahnosl invariably })r(!sent in fatal cases. Lobar pneumonia is rare,
riourisy is common in some epidemics.
'Tho cardiac complications are also rare. In the heiglit of the fever a
systolic; murmur at the apex is not uncommon ; Ijut endocarditis, either
simple or malii::nant, is larely met with. Pericarditis too is very uncom-
mon. Myocarditis seems to be more fre(pient, and may be associated with
endarteritis of the coroiuiry vessels.
Of complications in the di<;estivc system, parotitis is rare. In severe
cases there is extensive pseudo-diphtheritic angina. Vomiting, which is
so marked a symptom in the early stage, is rarely persistent. Diarrhcea
is not uncommon, as noted by Sydenham, and is very constantly present
in children.
Albumimiria is frequent, but true nephritis is rare. Inflammation of
the testes and of the ovaries may occur.
Among the most interesting and serious complications are those per-
taining to the nervous system. In children convulsions are common. In
adults the delirium of the early stage may persist and become violent, and
Ihially subside into a fatal coma. Post-febrile insanity is occasionally met
with during convalescence, and very rarely epilepsy. Many of the old
writers spoke of paraplegia in connection with the intense backache of
the early stage, but it is probably associated with the severe agonising
lumbar and crural pains and is not a true paraplegia. It must be sepa-
rated from the form occurring in convalescence, which may be due to
peripheral neuritis or to a diffuse myelitis (Westphal). The neuritis
may as in diphtheria involve the pharynx alone, or it may be multiple.
Of this nature, in all probability, is the so-called pseudo-tabes, or ataxie-
varioUqne. Hemiplegia and aphasia have been met with in a few in-
stances, the result of encephalitis.
Among the most constant and troublesome complications of small-pox
are those involving the skin. During convalescence boils are very fre-
quent and may be severe. Acne and ecthyma are also met with. Local
gangrene in various parts may occur.
Arthritis may develop, usually in the period of desquamation. It is
5
56 SPECIFIC INFECTIOUS DISEASES.
probably not a genuine rheumatism. Acute necrosis of the bone is some-
times met with.
Special Senses. — The eye affections which were formerly so common
and serious are not now so frequent, owing to the care which is given to
keeping the conjunctivae clean. A catarrhal and purulent conjunctivitis
is common in severe cases. The secretions cause adhesions of the eyelids,
and unless great care is taken a diffuse keratitis is excited, which may go
on to ulceration and perforation. Iritis is not very uncommon. Otitis
media is an occasional complication, and usually results from an extension
of disease through the Eustachian tubes.
Prognosis. — In unprotected persons small-pox is a very fatal disease.
In different epidemics the death-rate is from 25 to 35 per cent. The
haemorrhagic form is invariably fatal, and a majority of those attacked
with the severer confluent forms die. In young children it is particularly
fatal. In the Montreal epidemic of 1885 and 1886, of 3,164 deaths there
were 2,717 under ten years. The intemperate and debilitated succumb
more readily to the disease. As Sydenham observed, the danger is direct-
ly proportionate to the intensity of the disease on the face and hands.
" When the fever increases after the appearance of the pustules, it is a bad
sign ; but, if it is lessened on their appearance, that is a good sign "
(Rhazes). In the confluent cases, when maturation does not proceed
and the pocks are flat and if haemorrhage occurs, the outlook is usually
bad. In such cases the general symptoms are apt to be severe. Very
high fever, with delirium and subsultus, are symptoms of ill omen. The
disease is particularly fatal in pregnant women and abortion usually takes
place. It is not, however, uniformly fatal, and I have twice known severe
cases to recover after miscarriage. Moreover, abortion is not inevitable.
Very severe pharyngitis and laryngitis are fatal complications.
Death results in the early stage from the action of the poison upon the
nervous system. In the later stages it usually occurs about the eleventh
or twelfth day, at the height of the eruption. In children, and occasion-
ally in adults, the laryngeal and pulmonary complications prove fatal.
Diagnosis. — During an epidemic, the initial chill, followed by fever,
headache, vomiting, and the severe pain in the back, are symptoms which
should put the attending physician on his guard. Mistakes arise in the
initial stage owing to the presence of the scarlatinal or measly rashes
which may be extremely deceptive. The scarlatinal rash has not always
the intensity of the true rash of this disease. In my Montreal experience
I did not meet with an instance in which this rash led to an error, though
I heard of several cases in which the mistake was made. These are doubt-
less the instances to which the older writers refer of scarlet fever and
small-pox occurring together. The measly rash cannot always be dis-
tinguished from true measles, instances of which may be mistaken for the
initial rash. I found in the ward one morning a young man who had
been sent in on the previous evening with a diagnosis of small-pox. He
SMALL rox. 57
hiul a fading macular rasli wifli (llMlincI Hmall papiilrH, wljuh hu'l not
however (lie Hliitttv lianiiicHH of variola. In tiir cvciiiii^ lliin raMli wiix Ichji
iiiarkiMl, aiul as I felt, Hiin- that a iniHtaki" lia<l \n-r\\ iiuul«*, hr wax ilinin-
footcd and sent Imiiic In aiiotluT inHtanci; a ciiiM Ixdiovcd U> hav<! Hriiull-
jM>\ was ailinittrd, l)iil, it proved lo Imvn niinply ineartlrH. Neither of llu'ioj
CU80H took Hniail-[n»\. Ill a third ciihu, wliich I Haw at tin; City IIoM|»ital,
tho inotlh'd papnhir rasli was niislakcn for Kniall-pox and tin* \onn^' man
8('nt to th(> hos|)ital. I saw him thu day after admission, when there wjw
no (pieslion that llie disease was meash'S and not variola. Less fortumit4)
than the oihci- caHeH, ho took Hnndl-pox in a wvy Kcvcro form. Tlit* f^vu-
oral eondilion of the patient and t hi; nature of the pi-<idromal HymptornH
are often hettei- i,Miides than t he charac^ter (»f the rash. Jn any case it in
not well, as a rule, to send a patient to a snudl-j)ox hospital until tlio ehar-
ucteristie papules appear about the forehead ami on the wrists.
In the most malignant type of luemorrhagie small-])ox the patient may
die before the charaetoristic rash develops, though as a rule small, shotty
papules nuxy be felt about the wrists or at the roots of the hair. In only
one of twenty-soven cases of luvmorrhagic snuiU-pox, in which death
occurred on the third day, did inspection fail to reveal the })a})ule8. In
three cases in which death took place on the fourth day the characteristic
rash was beginning to appear.
The disease may be mistaken for cerebro-spinal fever, in which purpuric
symptoms are not uncommon. A four-year-old child was taken suddenly
ill with fever, i)ains in the back and head, and on the second or third day
petechii^ appeared on the skin. There was retraction of the head, and
marked rigidity of the limbs. The haemorrhages became more abundant ;
and finally hi\3matemesis occurred and the child died on the sixth day. At
the post-mortem there were no lesions of cerebro-spinal fever and in the
deeply ha?morrhagic skin the papules could be readily seen. The post-
mortem diagnosis of small-pox was unhappily confirmed by the mother
taking the disease and dying of it.
It might be thonght scarcely possible to mistake any ether disease for
small-pox in the pustular stage. Yet I had an instance of a young man
sent to me with a copious pustular eruption, chiefly on the trunk and cov-
ered portions of the body, which, so far as the pustules themselves were
concerned, was almost identical with that of variola ; but the history and
the distribution left no question that it was a pustular syphilide. It is not
to be forgotten, however, that fever, which Avas absent in this case, may be
present in certain instances of diffuse pustular syphilis. Lastly, chicken-
pox and small-pox may be confounded. Indeed, sometimes it is not easy
to distinguish between them, though in well-defined cases of varicella the
more vesicular character of the pnistules, their irregularity, the short stage
of invasion, the slight constitutional disturbance, and the greater intensity
of the rash on the trunk, should make the diagnosis clear. It is stated
that the Chicago case, w^hich was the starting-point in Montreal of the
58 SPECIFIC INFECTIOUS DISEASES.
epidemic of 1885, was regarded as varicella and not isolated. If so, the
mistake was one which led to one of the most fatal of modern outbreaks
of the disease.
Glanders in the pustular form has been mistaken for small-pox, and I
know of an instance (during an epidemic) which was isolated on the sup-
position that it was variola.
Treatment. — In the interests of public health cases of small-pox
should invariably be removed to special hospitals, since it is impossible to
take the proper precautions in private houses. The general hygienic
arrangements of the room should be suitable for an infectious disease.
All unnecessary furniture and the curtains and carpets should be removed.
The greatest care should be taken to keep the patient thoroughly clean,
and the linen should be frequently changed. The bedclothing should be
light. It is curious that the old-fashioned notion, which Sydenham tried
so hard to combat, that small-pox patients should be kept hot and warm,
still prevails ; and I have frequently had to protest against the patient
being, as Sydenham expresses it, stifled in his bed. Special care should be
taken to sterilize thoroughly everything that has been in contact with
the patient.
In the early stage the pain in the back and limbs requires opium,
which, as advised by Sydenham, may be freely given. The diet should
consist of milk and broths, and of " all articles which give no trouble to
digestion." Cold drinks may be freely given. Barley-water and the
Scotch borse (oatmeal and water) are both nutritious and palatable.
After the preliminary vomiting, which is often very hard to check by
ordinary measures, the appetite is usually good, and, if the throat is not
very sore, patients with the confluent form take nourishment well. In
the haemorrhagic cases the vomiting is usually aggravating and per-
sistent.
The fever when high must be kept within limits, and it is best to use
either cold sponging or the cold bath. When the pyrexia is combined
with delirium and subsultus, the patient should be placed in a bath at 70°,
and this repeated as often as every three hours if the temperature rises
above 103°. When it is not practicable to give the cold bath, the cold pack
can be employed. These measures are much preferable in small-pox to
the administration of medicinal antipyretics.
The treatment of the eruption has naturally engaged the special atten-
tion of the profession. The question of the preventing of pitting, so much
discussed, is really not in the hands of the physician. It depends entirely
upon the depth to which the individual pustules reach. After trying all
sorts of remedies, such as puncturing the pustules with nitrate of silver, or
treating them with iodine and various ointments, I came to Sydenham's
conclusion that in guarding the face against being disfigured by the scars
" the only effect of oils, liniments, and the like, was to make the white
scurfs slower in coming ofi!." There is, I believe, something in protecting
SMALL I'oX. 59
i\w ripening |»ipiiIrM fmiii l\w li^'lit, uikI tiio roiiMtant upj)li('ution on th»
fiUH) uiid liaixis of lliit sdiikrd in cnlil wiitcr, to whidi uiitiHrptirM Hiich an
(•iirl)nli(' acid or Wicldoridn may '"' aildcil, Ih prrliapK tlm iiioMt Hiiita)d«)
treat iim'mL It is very plrasant to i\\r patifiil, and for IIh; fnai il in
W(dl to inal\(^ a mask in lint, wliirli can tlu'ii l>t) (.'ovi^nMl with oiled Milk.
\\ hen I lie cnists lu'^^Mii In form, tlic cliirf point is to keep them tlioroii^ldy
njoist, which mav Im- done l»y nil or ^dyccrin. TliiH pri^vt'ntH tln! dcHi<;ca-
tion and dilTusinn of ihr Hakes of <'pid<'rmis. \'asclin<! is particniarly iimc-
ful, and at this sla^^c may l)c freely nse(l upon tln^ fac<'. It fn'fjnently
relieves tlu^ itchini; also. I''or tlu; odor, which is HometimcH ho character-
istic! and disa«(reeahle, the dihit(^ carl)oli<r solutions arc probably be«t. If
the eruption is ahuiidaiit on the Hcalp, the hair should Ix; cut short to
prevent inattin«j^ and dccnmjtnsiiinii nf the (;ruHt8. During convulescencc
frequent, bathing is advisable, because it helps to soften the crusts. The
care of the eyes is particularly important, 'i'he lids should be thorougldy
cleansed three or four tinu'S a day, and the conjunctiviu washed with some
antiseptic solution, in the conlluent cases, when the eyelids are much
swollen and tlu' lids glued together, it is only by watchfulness that kerati-
tis can be prevented. The mouth and tliroat should be kept clean, and if
crusts form in the nose tliey should be softened by frequent injections.
Ice can be given, and is very grateful when there is much angina. In
moderate cases, so soon as the fever subsides the patient should be allowed
to get up, a practice which Sydenham warmly urged. The diarrha^a, when
severe, should be checked with paregoric. When the pulse becomes feeble
and rapid, stimulants may be freely given. The delirium is occasionally
maniacal and may require chloroform, but for the nervous symptoms the
bath or cold pack is the best. For the severe haemorrhages of the malig-
nant cases nothing can be done, and it is only cruel to drench the unfortu-
nate patient with iron, ergot, and other drugs. Symptoms of obstruction in
the larynx, usually from oedema, may call for tracheotomy. In the late
stages of the disease, should the patient be extremely debilitated and the
subject of abscesses and bed-sores, he may be placed on a water-bed or
treated by the continuous warm bath. During convalescence the patient
should bathe daily and use carbolic soap freely in order to get rid of the
crusts and scabs. The patient should not be considered free from danger
to others until the skin is perfectly smooth and clean, and free from any
trace of scabs. I have not mentioned any of the so-called specifics or the
internal antiseptics, which have been advised in such numbers ; because,
so far as I know, the experience of those who have seen the most of the
disease does not favor their use.
eo SPECIFIC INFECTIOUS DISEASES.
V. VACCINIA {Cow-pox)-V ACCINATION.
Definition. — An eruptive disease of the cow, the virus of which, inocu-
lated into man (vaccination), produces a local pock with constitutional dis-
turbance, which affords protection, more or less permanent, from small-pox.
The vaccine is got either directly from the calf — animal lymph — in
which the disease is propagated at regular stations, or is obtained from
persons vaccinated (humanised lymph).
It was in 1798 that Edward Jenner, a friend and pupil of Hunter,
practising in Gloucestershire, announced that persons accidentally inocu-
lated with the cow-pox were subsequently insusceptible to small-pox.
From that time the process has extended over the civilized world and
proved an incalculable boon to humanity. For many years arm-to-arm
vaccination was practised, or the lymph was collected from the vesicle of
a child, or the dried scabs were used. The humanised lymph in all proba-
bility underwent changes and was certainly more frequently followed by
evil results. Of late years animal vaccination has superseded it in great
part, and now the lymph is derived either directly from the calf or from
one or two removes.
The precise nature of the vaccination virus is as yet unknown. Sev-
eral forms of micro-organisms have been isolated, and Quist has cultivated
micrococci which, he states, produce in the child a typical vaccine vesicle.
Several attempts have since been made to isolate the virus, but without
definite success. Ernst and Martin, of Boston, have isolated from the
bovine lymph a germ which grows on culture media and produces, when
inoculated in the calf or in children, characteristic vesicles.
Phenomena of Vaccination. — In a primary vaccination, at the
end of twenty-four or thirty-six hours there is seen at the point of inser-
tion of the virus a slight papular elevation surrounded by a reddish zone.
The papule gradually increases and on the fifth or sixth day shows a defi-
nite vesicle, the margins of which are raised while the centre is depressed.
By the eighth day the vesicle has attained its maximum size. It is round
and distended with a limpid fluid, the margin hard and prominent, and
the umbilication is more distinct. By the tenth day the vesicle is still
large and is surrounded by an extensive areola. The skin is also swollen,
indurated, and often painful. On the eleventh or twelfth day the hyperae-
mia diminishes, the lymph becomes more opaque and begins to dry. By
the end of the second week the vesicle is converted into a brownish scab
which gradually becomes dry and hard, and in about a week (that is, about
the twenty-first or twenty-fifth day from the vaccination) separates and
leaves a circular pitted scar. If the points of inoculation have been close
together, the vesicles fuse and may form a large combined vesicle. Con-
stitutional symptoms of a more or less marked degree follow the vaccina-
tion. Usually on the third or fourth day the temperature rises, and may
persist, increasing until the eighth or ninth day. In children it is common
VACCINIA— VACCINATION'. ^J
to lmv(^ with tlu' f«<vor roHtloHHiu'HM, jMirti<'iiliirly lit nij(l»t, tiwl irrituhility ;
but as 11 rule these syiMptotiiM un< triviiil. If tlui iiirxMiliitidii jh nuulo on tho
arm, the avilhirv ^'hiiids hecoiiu" hir^'r and novt' \ if <in the Icjr, the in^^'iiinul
^laiiils. 'I'he al>nve may Im» taken as represent in;^' thr' typieiil conrHiMif viie-
cinatioii, whcl her performed with \\ni hnnianiKecl or with tho imirnal lymph.
Suoci'ssful vaeeinati(»n is, for a tinio at h-ast, an infallihhj protection
against small-pox. The dnralion of the immunity in extreriiely variable, dif-
ferin;^ in dilTeriMit individmds. In somo instances it is permanent, but a
nuijority of persons within ten or twelv(! years aj^^ain become susceptiblo.
licvaccination should be ])crformed between the tenth and fifteenth
year, and whenever snuill-pox is epideniio. The susceptibility to revucci-
nation is curiously variable, and when snuill-pox is prevalent it Ih not well,
if unsuccessful, to l)e content with a sin^de attempt. The ve«iele in re-
vaccination is usually smaller, has less induration and hyper;emia, and the
rcsultinijj scar is less juMfcct. Particular care should be taken to watch
the vesicle of rcvaccination, as it not infrc(iucntly ha])pens that a spurious
poi'k is formed, w liich reaches its hei<j;lit early and dries to a scab by the
eighth or ninth day. The constitutional symptoms in revaccinaticjii are
sometimes quite severe.
An irregular course is uncommon in })rimary vaccination, but we occa-
sionally meet with instances in which tlie vesicle develo])S rapidly with
much itching, has not the characteristic flattened appearance, tlie lymph
early becomes opaque, and the crust forms by the seventh or eighth day.
In such cases the operation should again be performed with fresh lymph.
Complications. — In unhealthy subjects, or as a result of uncleanli-
ness, or sometimes injury, the vesicles inflame and deep excavated ulcers
result. Sloughing and deep cellulitis may follow. In debilitated chil-
dren there may be with this a purpuric rash. Erysipelas may occur, or
there may be deep gangrenous ulceration. Such instances are rare, but
I have seen two which proved fatal. In one there was deep sloughing and
in the other erysipelas. Cases of local dermatitis must not be mistaken
for erysipelas. Among the most common complications are certain skin
eruptions, some of which are due to the vaccine virus ; others result from
a mixed infection. Vaccine vesicles not infrequently break out in the
immediate vicinity of the primary sores. Less commonly there is a gen-
eral eruption of vesicles — generalized vaccinia — due to absorption of the
virus. More frequent, perhaps, is the erythematous or roseolous rash.
Contagious impetigo can also be inoculated with the virus, and may
appear as a general eruption.
A question of special importance with reference to vaccination is the
transmission of other diseases. For a time physicians were unwilling to
acknowledo^e that constitutional disorders could be transmitted bv vaccina-
tion, but it is now universallv recos^nized that such transmission mav take
place, and this has emphasised the scrupulous care which should be taken
in the performance of the operation.
62
SPECIFIC INFECTIOUS DISEASES.
Vaccino-Syphilis. — For a knowledge of this most serious of all accidents
during vaccination we are largely indebted to Jonathan Hutchinson. It is
a true instance of a mixed infection. The vaccine vesicles take as a rule
their usual course, and it is not until they have healed or are in process of
healing that the local changes characteristic of syphilis are manifested.
The fact that syphilis may be transmitted in this way should put the prac-
titioner on his guard in selecting humanised lymph. He should take it
only from subjects with whose constitution he is perfectly familiar.
Fortunately, the instances are extremely rare. They are, in fact, much
less frequent than is usually supposed, and in a majority of the cases in
which vaccino-syphilis is suspected the condition is really that of inflamed
and indurated vaccinal ulcer. As the subject is of daily interest to the
practitioner, and one which he may at any moment be called upon to de-
cide, I here insert a table of differential features between vaccinal ulcers
and vaccino-syphilis, and between the vaccination rashes and the secondary
syphilitic eruptions, compiled by C. E. Shelly * from Fournier's lectures.
YACCIXO-SY PHILIS.
Chancre developed on the site of
usually one or two only of the vac-
cination punctures.
Inflammation is slight.
Loss of substance superflcial only.
Suppuration scanty or absent,
scabs or crusts formed.
Border of chancre smooth, slight-
ly elevated, gradually merging into
floor.
Surface of floor smooth.
Induration " parchment - like "
and specific, not merely inflammatory.
Inflammatory areola very slight.
Gland swelling constant, indo-
lent (syphilitic) bubo.
Complications rare.
Chancre never developed before
the fifteenth day after vaccination ;
usually not until after three to five
weeks ; still in its earlier stage
twenty days after vaccination.
VACCINATION^ ULCERS.
Ulceration affects all the punct-
ures as a rule.
Inflammation and ulceration se-
vere.
Ulcer deeply excavated.
Much suppuration.
Margin of ulcer irregular, as in
" soft chancre."
mg.
Floor of ulcer uneven, suppurat-
Induration inflammatory only.
Areola inflammatory and ery-
sipelatous in character.
Gland swelling often absent; if
present, merely inflammatory.
Complications — sloughing, ery-
sipelas, etc. — often present.
Ulceration is present twelve or
fifteen days after vaccination and is
fully developed by the twentieth
day after vaccination.
* Fowler's Dictionary of Medicine. Article Vaccination.
VACCINIA VACCINATION.
08
MKCONDAItY HYI'IIIMTIC Kill' ITION
(liM» lo Inic viicciii(»-sN philis.
AppcjirH, at I1m» (»arlit's(, nine or
ten weeks jifler vaeeinalioii.
Ko(iuii-es, ill every caso, tlie pre-
oxisteiice of a specilie ulcer (elumcro)
lit tho site of vaeeiiiation.
Exhibits tlio characters of a true
apecitic eruption.
Fever often sli^^ht.
Lasts for a K)iig time.
Usually accompanied by specific
appearances on mucous membranes.
VACCIXO-SYPIIILIS.
Begins witli a local infection,
chancre and indolent bubo.
Typical development in four
stages, viz., incubation, chancre,
second incubation, generalization
(secondary eruptions, etc.).
Never appears earlier than the
ninth or tenth week after vaccina-
tion.
VA<X'INATlO.V KAHIIKH
(iiieludin^ToMeohi varcinaiiM,niiliuria
vueejiuiliH, vaeeinia biilloHu, vaccinia
lui'Miorrha^'ica); ulHouccidtrritul erup-
tions— rub<5olu, Hcarlatina, liclurn,
urticaria, etc.
A true va<*eimil ranh appearn })C-
tween tlu! ninth and fifte(;nth day
afti'r vac(!ination.
Absence of inoculation chancre.
Kru})tion does not exhibit Hpe-
cilic characters.
Fever always present.
Evanescent.
HKUKDITAUV SYF'HIMS SHOWING
ITSELF AIJOUT THE TIME OF
VACCINATION.
No chancre ; begins with gen-
eral phenomena.
Has no typical development in
connection with vaccination.
Time of development quite inde-
pendent of vaccination.
Is attended by the characteristic
syphilitic bodily aspect.
Other manifestations of heredi-
tary syphilis may be present.
The history may indicate syphilis.
Choice of Lymph. — Humanised lymph should be taken on the
eighth day and only from perfectly formed unbroken vesicles, which have
had a typical course, and have not yet developed areolae. Pricking or
scratching the surface, the greatest care being taken not to draw blood,
allows the lymph to exude, and it may then be collected on ivory points or
in capillary tubes. The child from which the lymph is taken should be
healthy, strong, and known to be of good stock, free from tuberculous or
syphilitic taint. Under these circumstances humanised lymph, one or
64 SPECIFIC INFECTIOUS DISEASES.
two removes from the calf, is usually very satisfactory in its action and is
perfectly reliable.
In the case of the calf the most scrupulous care should be exercised in
the vaccine farms to secure animals which are healthy and strong. The
risk, however, that the calf has any disease which can be transmitted to
man is exceedingly slight, as tuberculosis is very rare in cattle when young.
Unquestionably, however, there may be risk in the case of a calf born of
tuberculous parents, and special care should be taken in the selection of
proper animals. There is no essential difference in the pocks which fol-
low humanised lymph and bovine lymph. It was, I believe, a common
experience in Montreal that children inoculated with bovine lymph had
more constitutional disturbance and often sorer arms than those vaccinated
with humanised lymph at one or two removes.
In the performance of the operation that part of the arm about the in-
sertion of the deltoid is usually selected. Mothers " in society " prefer to
have girl babies vaccinated on the leg. The skin should be cleansed
and put upon the stretch. Then, with a lancet or the ivory point, cross-
scratches should be made in one or more places. When the lymph has
dried on the points it is best to moisten it in warm water. The clothing
of the child should not be adjusted until the spot has dried, and it should
be protected for a day or two with lint or a soft handkerchief. If erysipe-
las is prevalent, or if there are cases of suppuration in the same house, it
is well to apply a pad of antiseptic cotton. Vaccination is usually per-
formed at the second or third month. If unsuccessful, it should be re-
peated from time to time. A person exposed to the contagion of small-
pox should always be revaccinated. This, if successful, will usually pro-
tect; but not always, as there are many instances in which, though the
vaccination takes, variola also appears.
The Value ofVaccination. — Vaccination is not claimed to be an
invariable and permanent preventive of small-pox, but in an immense ma-
jority of cases successful inoculation renders the person for many years
insusceptible. Communities in which vaccination and revaccination are
thoroughly and systematically carried out are those in which small-pox
has the fewest victims. On the other hand communities in which vacci-
nation and revaccination are persistently neglected are those in which epi-
demics are most prevalent. In the German army the practice of revaccina-
tion has stamped out the disease. Nothing in recent times has been more
instructive in this connection than the fatal statistics of Montreal. The
epidemic which started in 1870-'71 was severe in Lower Canada, and per-
sisted in Montreal until 1875. A great deal of feeling had been aroused
among the French Canadians by the occurrence of several serious cases of
ulceration, possibly of syphilitic disease, following vaccination ; and several
agitators, among them a French physician of some standing, aroused a
popular and wide-spread prejudice against the practice. There were in-
deed vaccination riots. The introduction of animal lymph was distinctly
VACCINIA— VACCINATION. ^
bciK^nciul ill ('XlcMilin^ i\w \trnv.iir.i) iiruoii^' tin* lower cIummi-m, but rompiil-
Horv vacciiiiitinii could not Imi nirrird out. Ilftwcrn tlw y«'iirH 1H70 uikI
IHHl ji «'oMsi(l(«nil)lo uiiproU'ctiMl )Mipitliitioii ^'n-w up and lln* rniilrriiilH
woro riiM' fnr an (vxtrnsivd opidoinir. Tlu' Hoil had Immmi prrparrd with
tlio ^riuit(>Ht care and it <'idy luuMlcd tin- introduction of the hccd, wldcji in
(hictiiuc cainc as already HtaU^I with the I'nlhuan-cur conductor from
Chica'^^o, on tlu^ *>ISih of Kcljruary, 1HS:». Within the next t4'ii inoiithn
thousands of p(>isons were stricken with the disj-ase, and .'J, 104 died.
Alth()u;^h tlu^ elTt'cts of a single vaccination nuiy wear out, iw wo hh\\
and tlie individual ai;ain heconie susceptihh^ to small-pox, yet the mortal-
ity in such cases ia vory much lower tlian in persons who have never been
vacciiuiteil. Thi' mortality in persons wiio have been vacriruited is from
G to 8 per cent, whereas in the unvaceinated it is at least 35 per cent,
^farson jiointed out some years a^o that there is a definite ratio l)etween
the number of deatlis and tiu^ number of <^ood vaccimition marks in post-
vaccinal snudl-]>ox. With ^ood marks the nu)rtality is between 3 and 4
per cent, and wiili indilTeront marks at least 10 or 11 per cent.
VI. VARICELLA (Chicken-pox).
Definition. — An acute contagious disease of children, characterised
by an erui)tion of vesicles on the skin.
Etiology. — The disease occurs in epidemics, but sporadic cases are
also met with. It may prevail at the same time as small-pox or may fol-
low or precede epidemics of this disease. An attack of chicken-pox is no
protection against small-pox. It is a disease of childhood ; a majority of
the cases occur between the second and sixth years. It is rarely seen in
adults. The bacteriological examination of the vesicles has shown the
presence of micrococci in the contents of the vesicles, but the specific germ
has not yet been discovered.
There can be no question that varicella is an affection quite distinct
from variola and without at present any relation whatever to it. An at-
tack of the one does not confer immunity from an attack of the other.
The case which Sharkey reported is of special importance in this connec-
tion. A boy, aged five, was admitted to St. Thomas' Hospital with a
vesicular eruption, and was isolated in a ward on the same floor as the
small-pox ward. Tlie disease was pronounced chicken-pox, however, by
Sir Risdon Bennett and Dr. Bristowe. The patient was then removed
and vaccinated, with a result of four vesicles which ran a pretty normal
course. On the eighth day from the vaccination the child, became fever-
ish. On the following day the papules appeared and the child had a well-
developed attack of small-pox with secondary fever.
Symptoms. — After a period of incubation of ten or fifteen days the
child becomes feverish and in some instances has a slight chill. There
QQ SPECIFIC INFECTIOUS DISEASES.
may be vomiting and pains in the back and legs. Convulsions are rare.
The eruption usually develops within twenty-four hours. It is first seen
upon the trunk, either on the back or on the chest. I have seen it, however,
appear first on the forehead and face. At first in the form of raised red
papules, they are in a few hours transformed into hemispherical vesicles
containing a clear or turbid fluid. There is no umbilication as in the
vesicles of small-pox. They are often ovoid in shape and look more super-
ficial than the variolous vesicles. The skin in the neighborhood is neither
infiltrated nor hyperaemic. At the end of thirty-six or forty-eight hours
the contents of the vesicles are purulent. They begin to shrivel and dur-
ing the third and fourth days are converted into dark brownish crusts,
which fall off and as a rule leave no scar. Fresh crops appear during
the first two or three days of the illness, so that on the fourth day one can
usually see pocks in all stages of development and decay. They are al-
ways discrete and the number may vary from eight or ten to several hun-
dreds. As in variola, a scarlatinal rash occasionally precedes the develop-
ment of the eruption.
There are one or two modifications of the rash which are interesting.
The vesicles may become very large and develop into regular bullae, look-
ing not unlike ecthyma. The irritation of the rash may be excessive, and
if the child scratches the pocks ulcerating sores may form, which on heal-
ing leave ugly scars. Indeed, cicatrices after chicken-pox are not so very
uncommon. They are in my experience more common than after vario-
loid. The fever in varicella is slight, but it does not as a rule disappear
with the appearance of the rash. The course of the disease is in a large
majority of the cases favorable and no ill effects follow. The disease may
recur in the same individual. There are instances in which a person has
had three attacks.
There are one or two interesting complications of chicken-pox. In
delicate children, particularly the tuberculous, gangrene may occur about
the vesicles (Abercrombie).
Cases have been described (Andrew) of haemorrhagic varicella with
cutaneous ecchymoses and bleeding from the mucous membranes.
Nephritis may occur. Infantile hemiplegia has developed during an
attack of the disease.
The diagnosis is as a rule easy, particularly if the patient has been
seen from the outset. When a case comes under observation for the first
time with the rash well out, there may be considerable difficulty. The
pocks in varicella are more superficial, more bleb-like, have not the
infiltrated areola about them, and may usually be seen in all stages of
development. They rarely at the outset have the hard, shotty feeling of
small-pox. The general symptoms, the greater intensity of the onset, the
prolonged period of invasion, and the more frequent occurrence of prodro-
mal rashes in small-pox are important points in the diagnosis.
No special treatment is required. If the rash is abundant on the
SCAKIJT FKVKK. 07
fnc(^ griMit euro hIioiiM Ix* taken to pruvoiit l\w child from Hcrutching the
pusttih'M. A Hootliiii;; lotion Hhoiild b(? jipplird on lint.
VII. SCARLET FEVER.
Definition. An infections disujuso clmnictorisc(l ))y u difliiHo exan-
thcin Mild an ani^ina id' viiriji!)lc intensity.
Etiolojjy. — Wo owe tlie recognition of scarlel fever ha u diHtinct din-
ease to S)(lei;!iani, before whose time it wjih C()ufounde<l with meuwlcH. It
is a wide-spri'ad alTection, occurrin;; in nearly all parts of the globe and
attacking all races.
'i'he disease occnrs sporadically from time to time, and then under
unknown conditions becomes wide-spread, epidemics vary in severity.
Among prcilisposing factors age is most important. A large j)ropor-
tiou of the eases occur before the tenth year. Of an enormous mnnber of
fatal cases tabulated by Murchison over IK) per cent occurred in cliildren
under this age. Adults, liowever, are by no means exempt. Very young
infants are rarely attacked. A certain number exposed to the contagion
escape. In a family of children all more or less exposed one or two may
uot take the disease, wliereas all as a rule, if exposed, take the measles.
The susceptibility seems to vary in families, and we meet occasionally with
sad instances in w hich three or more members of a family succumb in
rapid succession.
Males and females are equally alTected.
Epidemics prevail at all seasons, but perhaps with greater intensity in
autumn and winter.
The contagion of scarlet fever is probably not developed until the erup-
tion appears, and is particularly to be dreaded during desquamation. No
doubt the poison is spread largely by the fine scaly particles which are
diffused with, the dust throughout the room. Even late in the disease,
after desquamation has been apparently completed, a patient has con-
veyed the contagion. The poison clings with great persistence to cloth-
ing of all kinds and to articles of furniture in the room. In no disease is
a greater tenacity displayed. Bedding and clothes which have been put
away for months or even for years may, unless thoroughly disinfected,
convey contagion. Physicians, nurses, and others in contact with the
sick may carry the poison to persons at a distance. It is remarkable that
in the case of physicians this does not more frequently occur. I know of
but one instance in which I carried the contagion of this disease. The
poison probably is not widely spread in the atmosphere. Observations
have been recently made wliich indicate that the poison may be conveyed
in milk. The epidemic investigated by Power and Klein in London in
1885 was traced by them to milk obtained from a dairy at Hand on, in
which the cows were found to be sufferins: from a vesicular affection of
68 SPECIFIC INFECTIOUS DISEASES.
the udder. The nature of this disease of the cow is doubtful, however.
Crookshauk maintains that it was cow-pox, and had nothing to do with
scarlet fever.
Some writers maintain that scarlet fever may be associated with de-
fective house-drainage. Possibly the virus may occasionally gain entrance
in this way.
The attack does not necessarily protect permanently. There are in-
stances of a second and even a third attack.
Surgical and puerperal scarlatinas, so called, demand a word under this
section. While scarlet fever may attack a person after operation, or a
woman in childbed, the majority of the cases described as such represent,
I believe, only the red rash of septicaemia. In the cases which I have seen
the rash was rarely so widespread as in scarlet fever ; the tongue had not
the special features, nor was the throat affected. Desquamation is no cri-
terion, as it occurs whenever hyperaemia of the skin persists for any length
of time. It is interesting to note that these cases have become rare with
the gradual disappearance of septicaemia. I. E. Atkinson suggests that
these rashes are in many cases due to quinine.
Attempts to determine the specific germ of scarlet fever have so far
proved ineffectual. Occasionally streptococci are found in the blood, and
in fatal cases they are found in the lymph-glands and in the kidneys. It
will no doubt soon be determined whether Loeffler's bacillus of diphthe-
ria exists in the pseudo-membranes in the throat. Cornil and Babes state
that it does, and that in the angina without diphtheria there are only
streptococci. In some cases the bacillus of diphtheria has been found late
in the disease. The point is one of great importance, and could be set-
tled by careful observations.
Morbid Anatomy. — Except in the hasmorrhagic form, the skin
after death shows no traces of the rash. There are no specific lesions.
Those which occur in the internal organs are due partly to the fever and
partly to infection with pus-organisms.
The anatomical changes in the throat are those of simple inflamma-
tion, follicular tonsillitis, and, in extreme grades, of pseudo-membranous
angina. In severe cases there is intense lymphadenitis and much inflam-
matory oedema of the tissues of the neck, which may go on to suppuration,
or even to gangrene. Streptococci are found abundantly in the glands
and in the areas of suppuration. Of changes in the digestive organs, a
catarrlial state of the gastro-intestinal mucosa is not uncommon. The
liver may show interstitial changes (Klein). The spleen is often enlarged.
Endocarditis and pericarditis are not infrequent. Myocardial changes
are less common. The renal clianges are the most important, and have
been thoroughly studied by Coats, Klebs, Wagner, and others. The spe-
cial nephritis of tlie disease will be considered with the diseases of the
kidney.
Affections of the respiratory organs are not frequent. When death
SCAULF/r KKVKR. 69
n^sultM from the psciidn nu^nihniiuniH iiii^nim, Ijroiicho-pnr'umoiiia in not
uiic<HMm(tii. ( 'crchio sjiiiml ('lmn;^M'H jin* riirr.
Symptoms. Incubation, (hi tliin pnijit tlirn» in ^'n'ut t\iHrrv\niucy.
'Vhv pciKxl is iiiuloiilihdly very viiriul)lr. Krorn thn-e to twclvtj iluyn In
j)rnl)jil>ly tin- limil, llion;^Mi it iiuiy in cxcrptionul ciiHfH bo axU'iult'd. In
oiuM'iisc, (lie rirciiiiisiiuicrs (if w liicli iiia'ir it pcrffctly clear that I liad
niyHclf convt^yt'd lln- iufcctioji, ilic iiiciil>;itinri wiw twelve dayH.
Invasion. -Tlu' (HiHft iMiisa ruii' Huddcii. It may ix? preceded by aMii;,'i»t
sciircely nnticcuhlc indisposition. An actual cliill is rare. Vomiting and,
in youn^ clnldicn, convulsions arc common. 'I'lie fever is int^MiHe ; rising
rapidly, il may on ilic lirst day n-acli lol' or even 105°. Tbo skin Ih nn-
usually dry and to the touch gives a sensation of very pungent beat. Tbo
tongue is fui red, and as early as tbo first day there may be complaint of
dryness of tlic tliroat. Cougli and eatarrbal symi)toms are uncommon.
The face is often HusIumI and the jiatient has all the objective features of
an acute fever.
Eruption. — Usually on the second day, in some instances witbin twen-
ty-four liours, tlu' rasb develops in tbe form of scattered red points on a
deep subcuticular llusli. It a})})ears tirst on tbe neck and cbest, and
s})roads so rapidly tbat by tbe evening of tbe second day it may luive in-
vailed tbe entire skin. In pronounced cases tbo rash at its heigbt bas
a vivid scarlet hue, quite distinctive and unlike tbat seen in any other
eruptive disease. It is entirely hypera3mic, and the anaimia produced by
pressure instantly disappears. In some cases the rash does not become
uniform but renuuns patchy, and intervals of normal skin separate large
hyperivmic areas. Tiny papular elevations may sometimes be seen, but
they are not so common as in measles. At the height of the eruption
sudaminal vesicles may develop, the fluid of which may become turbid.
The entire skin may at the same time be covered with small yellow vesi-
cles on a deep red background. Pronounced cases of this type were
called by the older writers scarlatina miliar is.
Occasionally there are petechii^, which in the malignant type of the
disease become wide-spread and large. The eruption does not always ap-
pear upon the face. There may be a good deal of swelling of the skin
which feels uncomfortable and tense. The itching is variable ; not as a
rule intense at the height of the eruption. After persisting for two or
three days the rash gradually fades. The rash can often be seen on the
mucous membranes of the palate, the cheeks and the tonsils, giving to
these parts a vivid red, punctiform appearance. The tongue is red at the
tip and edges, furred in the centre ; and through the white fur are often
seen the swollen papilla?, which give the so-called " strawberry " appear-
ance to the tongue. The breath often has a very heavy, sweet odor.
The pharyngeal symptoms vary extremely. There may be —
1. Slight redness, with swelling of the pillars of the fauces and of the
tonsils.
105-8°
12 3 4
5 6 7 8 9
BSBBSnSB
bSbbBB!
mmmkrAWiffmm
SBBBBS8SS
104-0°
■■^^■■■^^■■■■■■■■H
■SiTlHHHHiiHHHHHHHHH
msmmamm
102-2°
■■■■■■■■■■■II^WHHBniH
BSSSSBBBBIBBSSiaB
BaBBBBBBBBBBfiSSBB
100-4°
BBBBBBBBBBBBBBiSBB
98-6°
70 SPECIFIC INFECTIOUS DISEASES.
2. A more intense grade of swelling and infiltration of these parts
with a follicular tonsillitis.
3. Membranous angina with intense inflammation of all the pharyn-
geal structures and swelling of the glands below the jaw, and in very se-
vere cases a thick brawny induration of all the tissues of the neck.
The fever, which sets in
with such suddenness and in-
tensity, may reach 105° or even
106°. It persists with slight
morning remissions, gradually
declining with the disappear-
ance of the rash. In mild cases
the temperature may not reach
103° ; on the other hand, in
very severe cases there may be
hyperpyrexia, the thermometer
registering 108° or even before
death 109°.
Eruption. rpj^g pulsc prcscuts the ordi-
Chart IX. — Scarlet fever (Striimpell). ^ i. -i i, l
^ ^ ' nary febrile characters, ranging
in children from 120° to 150°, or even higher. The respirations show an
increase proportionate to the intensity of the fever. The gastro intestinal
symptoms are not marked after the initial vomiting, and food is usually
well taken. In some instances there are abdominal pains. The edge of
the spleen may be palpable. The liver is not often enlarged. With the
initial fever nervous symptoms are present in a majority of the cases ; but
as the rash comes out the headache and the slight nocturnal wandering dis-
appear. The urine has the ordinary febrile characters, being scanty and
high colored. Albuminuria is by no means infrequent during the stage of
eruption, but the amount is slight. Careful examination of the urine
should be made every day. There is no cause for alarm in the slight trace
of albumen which is so often present, not even if it is associated with a
few tube-casts.
Desquamation. — With the disappearance of the rash and the fever the
skin looks somewhat stained, is dry, a little rough, and gradually the up-
per layer of the cuticle begins to separate. The process usually begins
about the neck and chest, and flakes are gradually detached. The degree
and character of the desquamation bear some relation to the intensity of
the eruption. When the latter has been very vivid and of long-standing,
large flakes may be detached. In rare instances the hair and even the
nails have been shed. It must not be forgotten that there are cases in
which the desquamation has been prolonged, according to Trousseau even
to the seventh or eighth week. The entire process lasts from ten to fifteen
or even twenty days.
There are cases of exceptional mildness in which the rash may be
scAUM'iT n:vi;i{. 71
pcuHM^Iy |)(«r(M«plil»lc. I>miM^' 4'|>i(lnmi(;M, wlioii wvrrul children of ii Iioiiim)-
linl<l iirr aiTrctcd^ it soinotiiiu'H imppcUH tluit ii riiild HickeiiH uk if of tu'urlct
fuvor, and has a son^ tliroal and llio " HtrawlxTrv ton^^iu;" without th<* de-
vclopMU'iit (»f any rash. Thin is tlu' Ho-callcd smrhttiiui sinr fru/itinnr.
Thesis sli^^ditcascM of Hcurh't f'-vi'i* may be? f<»II<.\\ti| hv the -••\i-n--t al-
tacks of lu'piiritis.
MALKINANT SCAKUrr FIlVKi:.
Ataxic Form. — This prc.^^tMits all tlu! characteriHtics of an acuto intoxi-
cation. 'I lu' |>ali(Mit ovcrwlu'lnu'd hy the intensity of the j)oison may dio
within twiMity-four or thirty-six hours. 'J'lie discju^e s«*tH in with great
sovority — hi^h fevor, extreme restlessness, headache, and delirium. 'J'hc
ti'inpcrature may rise to loi" or even 108°, and rare cases have been ob-
serveil in wliieh the thermometer h;is registered even lii<;her. (.'onvulsion.s
may occur in cluldren. The initial delirium rapidly ^ives place to coma.
Th(^ dyspmea may ho urgent; the })ulse is very rapid and feeble.
Hemorrhagic Form. — In some instances ha'morrhages occur into the
skin. There is ha'niaturia, and epistaxis. In the erythematous rasn there
are at lirst scattered petechia*, wliich <j^radually become more extensive,
and ultimately the skin may be universally involved. Death may take
place on the second or on the third day. While this form is perhaps
more common in enfeebled children, I have twice known it to attack per-
sons a})parently in full health.
Anginose Form. — The throat symptoms may appear early and progress
rapidly. The fauces and tonsils are swollen. ^lembranous exudation
forms. It may extend to the posterior wall of the pharynx, forward
into the mouth, and upward into the nostrils. The glands of the neck
rapidly enlarge. Xecrosis occurs in the tissues of the throat, tlie fcetor is
extreme, the constitutional disturbance profound, and the child dies with
the clinical picture of a malignant diphtheria. Occasionally the mem-
brane extends into the trachea and the bronchi. The Eustachian tubes
and the middle ear are usually involved. In cases in which death does
not take place rapidly from toxemia there may be extensive abscess forma-
tion in the tissues of the neck and sloughing. In the separation of deep
sloughs about the tonsils the carotid artery may be opened, causing fatal
haemorrhage.
As already mentioned, scarlatinal angina, though resembling diphthe-
ria and not to be distinguished from it anatomically, is probably due to
the scarlatinal and not to the diphtheritic poison.
Complications and Sequelae. — (a) XepJirifis. — At the height of
the fever there is often a slight trace of albumen in the urine, which is
not of special significance. In a majority of cases the kidneys escape
without greater damage than occurs in other acute febrile affections.
Nephritis is most common in the second or third week and may de-
velop after a very mild attack. It mav be delayed until the third or
6
72 SPECIFIC INFECTIOUS DISEASES.
fourth week. As a rule, the earlier it develops in the disease the more
intense it is. It varies greatly in intensity, and three grades of cases may
be recognized :
1. Very severe cases with suppression of urine or the passage of a
small quantity of dark bloody urine laden with albumen and tube-casts.
Vomiting is constant, there are convulsions, and the child dies with the
symptoms of acute uraemia.
2. Less severe cases without any serious acute symptoms. There is a
puffy appearance of the eyelids, with slight oedema of the feet ; the urine
is diminished in quantity, smoky in appearance, and contains albumen
and tube-casts. The kidney symptoms then dominate the entire case, the
dropsy persists, and there may be effusion into the serous sacs. The case
may drag on and become chronic, or the patient may succumb to uraemic
accidents. Fortunately, in a majority of the cases the disease yields to
judicious treatment and recovery takes place.
3. Cases so mild that they can scarcely be termed nephritis. The
urine shows a moderate amount of albumen. There may be tube-casts,
rarely blood. The oedema is extremely slight or transient, and the conva-
lescence is scarcely interrupted. Occasionally, however, in these mild at-
tacks serious symptoms may supervene. Oedema of the glottis may prove
rapidly fatal, and in one case of the kind a child under my care died of
acute effusion into the pleural sacs.
There are instances of oedema without albuminuria or signs of nephri-
tis. Possibly in some of these cases the oedema may be haemic and due to
the anasmia ; but there are instances in which marked changes have been
found in the kidney after death, even when the urine did not show the
features characteristic of nephritis.
(b) Arthritis. — During the subsidence of the fever, rarely at its
height, pains and swelling in the joints may develop and present all the
characteristics of acute rheumatism. In all probability it is not however
true rheumatism, but is analogous to gonorrhoeal synovitis. It may pass on
to suppuration, in which case it most commonly involves only a single joint.
(c) Cardiac Complications.— SimiAe endocarditis is not uncommon,
and many cases of chronic valvular disease originate probably in the latent
endocarditis of this disease. Malignant endocarditis is rare. Pericarditis
is probably not more frequent, but is less likely to be overlooked than endo-
carditis. It usually develops during convalescence, and may be sero-fibrin-
ous or purulent. The cardiac complications are sometimes found in
association with arthritis. Myocarditis is not uncommon.
(d) Pleurisy may follow pneiimoyiia., though this is rare. More often
it occurs during convalescence, is insidious in its course, and as a rule
purulent. This serious complication of scarlet fever is not sufficiently
recognized. It was one upon which my teacher, R. P. Howard,* in Mont-
* Canada Medical and Surgical Journal, December, 1872,
SCAKLKT I'KVKK. 73
roiil, H|M'cially insishd in liin hurtiiroH. SlirrilT, in ji imiiiiImt of ilic; Htinu-
jounml, iTpnris two i-n^'^, oiTurrin^ at tin? hiimio time in hrotlnTH^ one of
whom (lied Muddciiiy uftn* 11 sli^dit cxcrtioM.
(r) l!nr ( 'iun/t/irttfidfis. -'I'lirsc arn coiTirnon and HcriniiH. TIkv jirc <1ih;
to oxti'iisioii of the inlliuniniitioii from thu tliroiit tiiroti^di the KiiHtuchiun
tubes. It is om^ of ilu* moHt fr('(|U('ijt cjiUHt'H of (IciifncKM. Tin? neverc
forniH of iiM-i)d>ninoii.s aii^iim hit almoHt alwavH iiMHociatctl with iiilhimma-
(ion of the iiiitltllt' car, which goes on to HWppuration and jtcrforation of
thi' iliiini. 'i'hc suppuration may extend to th(^ hil)yrintli and rapidly
prothu'c (h'-ifiu'ss. In other instances there is snpj)uration in tlie mastoid
0(»lls. In ih(! necrosis which foUows the mid(Ue-car disease, the facial
nerve may he involved and paralysis follow. Later, still more HeriouH
complieations may follow the otitis; sueh as thrombosis of the hiteral
sinus, meninu[itis, or abscess of the brain.
(/) A(/cfn'fis.— \n comparatively mild cases of scarlet fever the sub-
maxillary lymph-inlands may be swollen. In severer cases the swelling
of the neck becomes extreme and extends beyond the limits of the f^dands.
Acute phlegmonous inllammatiims may occur, leading to wide-spread de-
struction of tissue, in whicli vt'ssels may be eroded and fatal lia?morrhage
ensue. The suppurative processes may also involve the retro-pharyngeal
tissues.
The swelling of the lymph-glands usually subsides, and within a few-
weeks even the most extensive enlargement gradually disappears. There
are rare instances, however, in which the lymphadenitis becomes chronic
and the neck remains with a glandular collar which almost obliterates its
outline. This may prove intractable to all ordinary measures of treat-
ment. A case came under my observation in which, two years after scar-
let fever, the neck was enormously enlarged and surrounded by a mass of
firm brawny glands.
(g) Xervous ConipJicofions. — Chorea occasionally develops in connec-
tion with the arthritis and endocarditis. Sudden convulsions followed
by hemiplegia may occur. Two instances of progressive paralysis of the
limbs with wasting came under my observation at the Philadelphia In-
firmary for Xervous Diseases. The history was that of subacute ascending
spinal paralysis, but it is probable that they were instances of multiple
neuritis. Mental symptoms, mania and melancholia, have been described.
(//) Other rare complications and sequel* are eye affections, symmet-
rical gangrene, enteritis, and noma.
Diagnosis. — The diagnosis of scarlet fever is not difficult, but there
are cases in which the true nature of the disease is for a time doubtful.
The following are the most common conditions with which it may be
confounded.
1. Acrde Exfoliating Deniiafifis. — This pseudo-exanthem simulates
scarlet fever very closely. It has a sudden onset, with fever. The erup-
tion spreads rapidly, is uniform, and after persisting for five or six days
74: SPECIFIC INFECTIOUS DISEASES.
begins to fade. Even before it has entirely gone, desquamation usually
begins. Some of these cases cannot be distinguished from scarlet fever in
the stage of eruption. The throat symptoms, however, are usually absent,
and the tongue rarely shows the changes which are so marked in scarlet
fever. In the desquamation of this affection the hair and nails are com-
monly affected. It is, too, a disease liable to recur. Some of the instances
of second and third attacks of scarlet fever have been cases of this form of
dermatitis.
2. Measles, which is distinguished by the longer period of invasion,
the characteristic nature of the prodromes, and the later appearance of the
rash. The greater intensity of the measly rash upon the face, the more
papular character, the irregular crescentic distribution, are distinguishing
features in a majority of the cases. Other points are the absence of the
sore throat in measles and the peculiar character of the desquamation.
3. Rotheln. — The rash of rubella is sometimes strikingly like that of
scarlet fever, but in the great majority of cases the mistake could not
arise. In cases of doubt the general symptoms are our best guide.
4. SepticcBmia. — As already mentioned, the so-called puerperal or sur-
gical scarlatina shows an eruption which may be identical in appearance
with that of true scarlet fever.
5. Diphtheria. — The practitioner may be in doubt whether he is deal-
ing with a case of scarlet fever with intense membranous angina, or a true
diphtheria with an erythematous rash. The erythema in diphtheria may
appear early, before the throat symptoms are well developed, or as they
are appearing, in which case it is usually slight and disappears quickly.
There is also, when the disease is at its height, a later erythema, which
may be very diffuse and intense. The subsequent desquamation can not
always be relied upon to make clear the diagnosis, for any intense erythema
of sufficient duration will be followed by this process. None of the pre-
ceding conditions offer difficulties so great as these cases of angina with
erythematous rash, and it may be impossible to determine satisfactorily
the true nature of the trouble. Fortunately, so far as treatment is con-
cerned, this does not make much difference. A bacteriological examina-
tion of the exudate should be made in doubtful cases.
G. Drug Rashes. — These are partial, and seldom more than a transient
hyperaemia of the skin. Occasionally they are diffuse and intense, and in
such cases very deceptive. They are not associated, however, with the
characteristic symptoms of invasion. There is no fever, and with care the
distinction can usually be made. They are most apt to follow the use of
belladonna, quinine, and iodide of potassium.
Prognosis. — Epidemics differ in severity and the death-rate is ex-
tremely variable. Among the better classes the death-rate is much less
than in hospital practice. There are physicians who have treated consecu-
tively a hundred or more cases without a death. On tlie other hand, in
hospitals and among the poorer classes the death-rate is considerable,
scAKLKT I i;vi:r. 75
rai)<^ni);^' rioiii .'» (<> In per cent in mild fpiilciiiicH to 20 or 30 |M;r cent in
tlio vory Hnvi'ic.
'V\\{) youii;<('r I he child tlio ^Tcjitcr tln' daii^'cr. In infiiFitn iindtT oiu;
year ilic dcalli-nitc is very lii^di. 'I'lio ^njil proportion of fatal ca>iOH <x:-
CUTH in t'liildrcn under nix yearn of ap'.
'I'lie unfavorable HyniptoniH am very hi^di fovur, early rnj-ntai diHturh-
ance with ^M*eat jactitation, the occurrrncc nf lui'UUjrrhai^'eH (cutiincouH or
viaooral), intense pseudo-rneinbranouri an^iiui with cervical buho, and
signs of laryn«^a'al obstruction.
Nephritis is always a serious complication and when setting in with HUp-
prossiim of the urine nuiy (piickly prove fatal. It is noteworthy, however,
that a largo majority of the cases of scarlatinal nc})hriti8 recover.
Treatment. — Tlie disease cannot be cut sliort. In the presence of
the severer forms we are still too often lielpless. There is no disease in
which the successful issue and the avoidance of comj)licationH depends
more ui)on the skilled judgment of the {)hysiciaii and the care with which
his instructions are carried out.
The child should bo isolated and placed in charge of a competent
nurse. The temperature of the room should be constant and the ventila-
tion thorough. The child should wear a light flannel night-gown, and
the bedclothing should not be too heavy. The diet should consist of
milk, broths, and fresh fruits, and water should be freely given. With
the fall of the temperature, the diet may be increased and the child may
gradually return to ordinary fare. When desquamation begins the child
should be thoroughly rubbed every day, or every second day, with sweet
oil, which prevents the drying and the diffusion of the scales. An occa-
sional warm bath may then be given. At any time during the attack the
skin may be sponged with warm water. Tlie patient may be allowed to
get up after the temperature has been normal for ten days, but for at
least three weeks from this time great care should be exercised to prevent
exposure to cold. It must not be forgotten, also, that the renal complica-
tions are very apt to develop during the convalescence, and after all dan-
ger is apparently past. Ordinary cases do not require any medicine, or at
the most a simple fever mixture, and during convalescence a bitter tonic.
The bowels should be carefully regulated, either with small doses of calo-
mel or with mild aperients.
Special symptoms in the severe cases call for treatment.
AVhen the temperature is above 103° the extremities may be sponged
with tepid water. In severe cases, with the temperature rapidly rising, this
will not suffice, and more thorough measures of hydrotherapy should be
practised. With pronounced delirium and nervous symptoms the cold-
pack should be used. When the temperature is rising rapidly but the
child is not delirious, he should be placed in a warm bath, the temperature
of which can be gradually lowered. The bath at a temperature of 80° is
beneficial. In giving the cold-pack a rubber sheet and a thick layer of
76 SPECIFIC INFECTIOUS DISEASES.
blanket should be laid upon a sofa or a bed, and upon this a sheet,
wrung out of cold water. The naked child is then laid upon it and
wrapped in the blankets. An intense glow of heat quickly follows the
preliminary chilling, and from time to time the blankets may be un-
folded and the child sprinkled with cold water. The good effects which
follow this plan of treatment are often striking, particularly in allaying
the delirium and jactitation, and procuring quiet and refreshing sleep.
Parents will object less, as a rule, to the warm bath gradually cooled than
to any other form of hydrotherapy. The child may be removed from the
warm bath, placed upon a sheet wrung out of tolerably cold water, and
then folded in blankets. The ice-cap is very useful and may be kept con-
stantly applied in cases in which there is high fever. Medicinal antipy-
retics are not of much service in comparison with cold water.
The throat symptoms, if mild, do not require much treatment. Ap-
plications may be made with a spray, and if the laryngitis becomes severe
the measures should be used which will be mentioned under croup. Cold
applications to the neck are to be preferred to hot, though it is sometimes
difficult to get a child to submit to them. In connection with the throat
symptoms the ears should be specially looked after, and a careful disinfec-
tion of the throat by suitable antiseptic solutions should be practised.
When the inflammation extends through the tubes to the middle ear, the
practitioner should either himself daily examine the conditions of the
drum, or, when available, a specialist should be called in to assist him in
the case. The careful watching of this membrane day by day and the
puncturing of it if the tension becomes too great may save the hearing of
the child. With the aid of cocaine the drum is readily punctured. The
operation may be repeated at intervals if the pain and distention return.
No complication of the disease is more serious than this extension of the
inflammatory process to the ear.
The nephritis should be dealt with as in ordinary cases, and indications
for treatment will be found under the appropriate section. It is worth
mentioning, however, that Jaccoud insists upon the great value of milk
diet in scarlet fever as a preventive of nephritis.
Among other indications for treatment in the disease is cardiac weak-
ness, which is usually the result of the direct action of the poison, and is
best met by stimulants.
Many specifics have been vaunted in scarlet fever, but they are all use-
less. J. C. Wilson recommends chloral in one or two grain doses for a
child of two or three years.
MKASLKS. 77
VIII. mi:asles.
Definition. An ucutc, l»i;^'lil} inft'ctionH jliritrdcr, cliinicti-riiiwl Ijy
uii initial corv/ii Mini n nipidly Hpn'tidiii^ i^riiptiori.
Etiology. Till" inft'('(i(ni nf moiwleH ih very int<'nH4! and iiiiinuiiity
against attack iiol luMirly ho c(»iiiiiinn as in Hcarlct fuvcr. It in u <\m^ant' of
cliildliood, l)iit iinprotccti'd adults aro liablu to tho infection. Indeed,
nicasU's is more fretjiient. in adults than is scarh-t fever. Within the; firHt
six months of life the liability is not ho nuirked, thougli I have known in-
fants of a monlli and of six weeks to bo Htta(;kt'd. Tho boxch uro equally
alTected. Tiu^ conta^non is communicated by tlu^ l)natl» and by th(; w.'cre-
tions, particularly those of the nose. It nuiy bo conveyed by a third jkt-
son and by fomites.
'The disease is practically endemic in lar^e centres of population, and
from time to time spreads and ])revails epidemically. It occurs at all sea-
sons, but prevails more extensively during tho colder months. There is
no infectious diseasi' in which recurrence is rnoro frequent. There may
bo a second, third, or even a fourth attack.
Tho contagion of the disease is unknown. Xo one of the various or-
ganisms wliich liave been described meets the requirements of Koch's law.
Morbid Anatomy. — Measles itself rarely kills, but the complica-
tions and secpiehe ct)mbine to make it a very fatal affection in children.
There are no characteristic post-mortem appearances. The skin changes
are those associated with an intense hypertemia.
There is a catarrhal condition of the mucous membranes, particularly
of the bronchi. The fatal cases show almost invariably either broncho-
pneumonia, capillary bronchitis with patches of collapse, or less frequently
lobar pneumonia. The bronchial glands are invariably swollen. Pleurisy
is less common. During convalescence from measles there is a special lia-
bility to tuberculous invasion, and tuberculous broncho-pneumonia claims
a large number of victims. The bronchial glands may also be affected.
The gastro-intestinal mucosa may be hypera^mic. Swelling of Peyer's
glands is not at all uncommon and may reach a very intense grade in the
patches.
Symptoms. — Incubation. — This is about ten days, but the limits are
variable, and it may be as long as twenty days. The disease has been fre-
quently inoculated. In such cases the incubation period is less than ten
days.
Invasion. — The disease usually begins with symptoms of a feverish
cold. There are shiverings (not often a definite chill), marked coryza,
sneezing, running at the nose, redness of the eyes and lids, with photo-
phobia, and within twenty-four hours cough. These early catarrhal
symptoms are more marked in measles than in any other infectious disease
of children. There may be the symptoms so commonly associated with
an on-coming fever — nausea, vomiting, and headache. The tongue is
78
SPECIFIC INFECTIOUS DISEASES.
1010°
102-2=
100-4'
98.6'
96-8°
\mwiWMkmmi
VI ■■■■■^■■imiii
■■■■I
furred. Examination of the throat may show a reddish hjperaemia or in
some instances a distinct punctiform rash. Occasionally this spreads over
1 o 3 4 5 6 7 g the whole mucous membrane of
the mouth with the exception of
the tongue. The temperature at
this stage is usually high, reach-
ing from 103° to 104°, ascending
gradually through the second and
third days.
Eruption. — Usually on the
fourth day, when the fever and
general symptoms have reached
their height, the rash appears
upon the cheeks or forehead in
the form of small red papules,
which increase in size and spread
over the neck and thorax. When
the eruption becomes well devel-
oped the face is swollen and cov-
mmmmfmmMmmwKm
Initial Fever.
Eruptive Fever.
Eruption.
Chart X. — Measles (Striirapell).
ered with reddish blotches, which often have rounded or crescentic out-
lines. Here and there is an intervening portion of unaffected skin. At
this stage the cervical lymph-glands may be slightly swollen and sore.
The papules can now be felt with the finger. Sometimes they are quite
shotty, but do not extend deep into the skin. On the trunk and extremi-
ties the swelling of the skin is not so noticeable, the color of the rash not
so intense and often less uniform. The mottled blotchy character of the
rash appears most clearly on the chest or the abdomen. The rash is hy-
peraemic and disappears on pressure, but in the more malignant cases
it may become petechial. The general symptoms do not abate with
the occurrence of the eruption. They persist until the end of the fifth
or the sixth day, when in the majority of the cases all the symptoms be-
come mitigated. Among the peculiarities of the rash may be men-
tioned the development of numerous miliary vesicles and the occur-
rence of petechiae, which are seen occasionally even in cases of moderate
severity.
Desquamation. — After persisting for two or three days the rash gradu-
ally fades and desquamation occurs in the form of very fine branny
scales, which may be difficult to see and are wholly unlike the coarse ex-
foliation in scarlet fever.
The catarrhal symptoms gradually disappear and convalescence is
rapidly established.
In epidemics of measles atypical cases are common. The rash may
appear early, within thirty-six hours of the onset of the symptoms ; or, on
the other hand, it may be delayed until the sixth day. As in other exan-
thems, when many cases occur in a household, one of the children may
MKASLMS. 79
havo hII (lie iiiitiul Myin]»t()tnM und '^nickcn for i\w diitOfUM)/* an it in siiid,
l)iit. no (*ni|)iinii ii|)|M>iir.
'V\ui most McriniiM viiricly <»f iimmimIch is that, in wliidi hmmorrliat,'«'M oo-
(Uir — tli(' fnorlnlli /urmorr/idi/ici. In p-iuTal practice thfH«.« vhm-h uro vory
unoonunon. Occasionally in institntioiiH, particularly when tlio liygionin
sunoiiinlin^rs arc l»;nl, niic <>r two caMOH (lcv<*lop during an epidemic. It
has hccn frci|ii('ntly seen in canips and when the disiMise iH froHhly im-
ported into a native population, as in tho Fiji Islands. During' the civil
war, as shown l)y Smart's statistics, nnnw cases occurred.
In this form the disi'ase sets in witli much greater intensity, the rusli
becomes ])i»tecliial, lijemorrha«(es occur from the mucous memhrunes, the
constitutional depression is very great, and death occurs early from tox-
aemia.
Complications and Sequelae. — These are met with chietly in the
ros})iratory sysicin. The dani^cr conu's from the existing })ronchitis,
which is apt to extend into tiie smaller tubes and lead to collapse and
broncho-pneumonia. When limited in extent this causes only aggrava-
tion of the cougli and })ersistencc of the fever (symptoms which gradually
abate), and convalescence is rapid ; but in lU'bilitated children, more par-
ticuhirly in institutions and among the lower classes, tliis complication is
extremely grave and is responsible for the higli death-rate from measles
in the community. In some instances the clinical picture is that of a
suffocative catarrh, the result of a wide-spread involvement of the smaller
tubes. The description of the condition will be found under the section
Broncho-pneumonia. Lobar pneumonia is less common and perhaps less
dangerous.
Laryngitis is not uncommon : the voice becomes husky and the cough
croupy in character. (Edema of the glottis is very rare. Pseudo-mem-
branous inflammation of the pharynx and larynx may occur and prove
fatal. In debilitated infants severe stomatitis or even cancrum oris may
develop.
Catarrhal inflammation of the middle ear is not very uncommon, and
may proceed to suppuration and to perforation of the drum. The con-
junctival catarrh rarely leads to further trouble, though occasionally the
inflammation becomes purulent.
Intestinal catarrh is common in some epidemics, and there may be the
symptoms of acute colitis.
Nephritis is an exceedingly rare complication.
Of the sequelae of measles, tuberculosis is the most important — either
an involvement of the bronchial glands, a miliary tuberculosis, or a tuber-
culous broncho-pneumonia.
Among the rarer sequels of measles are paralyses. Hemiplegia is
very rare, but cases of paraplegia have been described. Thomas Barlow *
* Medico-Cliirurgical Society's Transactions, 1SS7.
80 SPECIFIC INFECTIOUS DISEASES.
reports a fatal case in which tlie symptoms occurred early, the paraly-
sis extended rapidly and involved the upper limbs, and death took place
on the eleventh day. Marked vascular changes were found in the gray
matter of the spinal cord, and were believed to depend on an early dissemi-
nated myelitis. Examination of the peripheral nerves was not made.
Similar cases are met with in the literature, and they probably come under
the division of the post-febrile polyneuritis, though of course it is not im-
possible that some of them, such as Barlow's case, may be due to a rapidly
ascending myelitis.
Diagnosis. — From scarlet fever, with which it is most likely to be
confounded, measles is distinguished by the longer initial stage with char-
acteristic symptoms, and the blotchy irregular character of the rash,
which is so unlike the diffuse uniform erythema of scarlet fever. Occa-
sionally in measles, when the throat is very sore and the eruption pretty
diffuse, there may at first be difficulty in determining which disease is
present, but a few days should suffice to make the diagnosis clear. It may
be extremely difficult to distinguish from rotheln. I have more than
once known practitioners of large experience unable to agree upon a
diagnosis. The shorter prodromal stage, the slighter fever in many cases,
are perhaps the most important features. It is difficult to speak definitely
about the distinctions in the rash, though perhaps the more uniform dis-
tribution and the absence of the crescentic arrangement are more constant
in rotheln.
The conditions under which measles may be mistaken for small-pox
have already been described. Of drug eruptions, that induced by copaiba
is very like measles, but is readily distinguished by the absence of fever
and catarrh.
Prognosis. — The mortality bills of large cities show what a serious
disease measles is in a community. Among the eruptive fevers it ranks
third in the death-rate. The mortality from the disease itself is not
high, but the pulmonary complications render it one of the most serious
of the diseases of children.
In some epidemics the disease is of great severity. In institutions and
in armies the death-rate is often high. The fever itself is rarely a source
of danger. The extension of the catarrhal symptoms to the finer tubes is
the most serious indication.
Treatment. — Confinement to bed in a well-ventilated room and a
milk diet are the only measures necessary in cases of uncomplicated
measles. The fever rarely reaches a dangerous height. If it does it may
be lowered by sponging or by the tepid bath gradually reduced. If the
rash does not come out well, warm drinks and a hot bath will hasten its
maturation. The bowels should be freely opened. If the cough is dis-
tressing, paregoric and a mixture of ipecacuanha wine and squills should
be given. The patient should be kept in bed for a few days after the
fever subsides. During desquamation the skin should be oiled daily.
mid warm hjitliH giviMi to fiMiliUito lln» pro(!Oiii. Tho foiivii!
from im-asloH is tlio most iiiipnrtjiiit hIu^'o of tlio diMmMO. Watrlim
aiul care may prrvtMit KciiouM ixilmonary romplicutirUiM. 'J'Im; fn'<|U. ;. .
with which tlir iimihrrHof childn-ir with KimpU? or tuhi-n'uloiiH hrone-ho-
piuMinumia tell u^ tliat, " tlio chihl caii^dit (-(.Id afU-r niciu^h'H/' and the
(•(»iitriii|»iati(>ii of the mortality liills nhoidd maki5 uh fxtremcdy cureful in
our inaiiaL,M'mtiil of this alTcction.
IX. RUBELLA {li''>(hdn, 0<rm(in Meanlrti).
Tliirt rxauthcm lias also tho numea of rubvula notltd, or epidomic rose-
ola, and, as it is supposed to present features common to botli, has been aUo
known as hybrid measles or liybrid scarlet fever. It is now generally re-
i^ard(Ml, however, as a separate and distinct alTection.
Etiology. — It is proj)a^'ated by conta<,Mon and spreads witli great
rapidity. It fre(piently attacks adults, anil the occurrence of either
measles or scarlet fever in childhood is no protection against it. The
epidemics of it are often very extensive.
Symptoms. — These are usually mild, and it is altogether a loss seri-
ous atTectiou than measles. Very exceptionally, as in the epidemics studied
by Cheadlo, the symi)toms are severe.
The stage of incubation ranges from ten to twelve days.
In the stage of invasion there are chilliness, headache, pains in the
back and legs, and coryza. There may be very slight fever. In 30 per
cent of Edwards's cases the temperature did not rise above 100°. The
duration of this stage is somewhat variable. The rash usually appears on
the tirst day, some writers say on the second, and others again give the
duration of the stage of invasion as three days. (JrifHth places it at two
days. The eruption comes out first on the face, then on the chest, and
gradually extends so that within twenty-four hours it is scattered over the
whole body. It may be the first symptom noted by the mother. The
eruption consists of a number of round or oval, slightly raised spot^, pink-
ish-red in color, usually discrete, but sometimes confluent.
The color of the rash is somewhat brighter than in measles. The
patches are less distinctly crescentic. After persisting for two or three
days (sometimes longer), it gradually fades and there is a slight fur-
furaceous desquamation. The rash persists as a rule longer than in scar-
let fever or measles, and the skin is slightly stained after it. The lym-
phatic glands of the neck are frequently swollen, and, when the eruption
is very intense and diffuse, the lymph-glands in the other parts of the
body.
There are no special complications. The disease usually progresses
favorably; but in rare instances, as in those reported by Cheadle, the
symptoms are of greater severity. Albuminuria may occur and even
82 SPECIFIC INFECTIOUS DISEASES.
nephritis. Pneumonia and colitis liave been present in some epidemics.
Icterus has been seen.
Diagnosis. — The mildness of the case, the slightness of the prodromal
symptoms, tlie mildness or the absence of the fever, the more diffuse
character of the rash, its rose-red color, and the early enlargement of the
cervical glands, are the chief points of distinction between rotheln and
measles.
The treatment is that of a simple febrile affection. It is well to keep
the child in bed, though this may be difficult, as the patient rarely feels
iU.
X. EPIDEMIC PAROTITIS (Slumps).
Definition. — An infectious disease, characterised by inflammation of
the parotid gland. The testes in males and the ovaries and breasts in
females are sometimes involved.
Etiology. — The nature of the virus is unknown. It is probably a
micro-organism, and a bacillus parotidis has been described.
The affection has all the characters of an epidemic disease. It is
said to be endemic in certain localities, and probably is so in large
centres of population. At certain seasons, particularly in the spring and
autumn months, the number of cases increases rapidly. It is met most
frequently in childhood and adolescence. Very young infants and adults
are seldom attacked. Males are somewhat more frequently affected than
females. In institutions and schools the disease has been known to attack
over 90 per cent of all the children. It may be curiously localised in a
city or district. The disease is contagious and spreads from patient to
patient.
A remarkable idiopathic, non-specific parotitis may follow injury or
disease of the abdominal or pelvic organs. Stephen Paget* has collected
101 cases of this kind, the majority of which were not associated with
septic processes.
Symptoms. — The period of incubation is from two to three weeks,
and there are rarely any symptoms during this stage. The invasion is
marked by fever, which is usually slight, rarely rising above 101°, but in
exceptionally severe cases going up to 103° or 104°. The child com-
plains of pain just below the ear on one side. Here a slight swelling is
noticed, which increases gradually, until, within forty-eight hours, there is
great enlargement of the neck and side of the cheek. The swelling passes
forward in front of the ear, and back beneath the sterno-cleido muscle. The
other side usually becomes affected within a day or two. The submaxil-
lary glands may also be involved. The greatest inconvenience is experi-
enced in taking food, for the patient is unable to open the mouth, and
* British Medical Journal, I\Iarch 19, 1887.
i.rii»i:Mic PAito'iiTis. g3
oven H)H>(M'li uikI ilf^Hiilitinii lircorno diniciilt. Tlicri) riiiiy Ix) nii increaae
ill llic H('( rclioii of titc Hiilivu, l)iit llir rovorM) iri HoriictiriioH i\w hum'. Then)
in Hdldnin '^wnl ))]iiii, l»iil, iiiHtnui, an iiiiplcuHuiit feeling (if U'riMJon uii'l
ti^litiii'SM. TIk IT iMiiy 1)13 ciiniciu) hikI hIj^'IiI iiiipuirriiciit of liniriii^.
After |M«rsiMtiii;^' for from hi'Vcm to ten <Iiivm, tlu* Hwrlliuj,' ^'nifiimlly
sii))si(l(>s and the (;ltil<l rapidly rr^uiiiH his Htrfn;^t)i and hcullii. l^dapMO
niri'ly if vsrv occnrM.
Occasionally the (liscasc is vrry severe an<l ejiaraetcrised hy hi;^'li
fovcr, dtliriiim, and i^icat prostration. Tlic patient nmy even lapse into
IX typhoid condition.
i)\w of the most reniarkaMe features of the disease is a tendency to
involvement of tlu^ testes. 'J'his most frefpiently rn-curs after th(; atT<-e-
tion of tlie salivary <^lands lias suhsided. The swelling may be ^reat, and
occasionally elTnsion taki'S place into the tunica vaginalis. The orchitis
is in some instances unilateral, involving the ri^ht testicle. The inflam-
mation increases for three or four ilays, and resolution takes place gradu-
ally. Occasionally there may he a muco-j)urulent dischar^^e. In severe
cases atrophy may follow. Orchitis is rarely seen before ])uberty.
A vulvo-vaijinitis sometimes occurs in girls, and the breasts may be-
come enlarc^ed and tender. Involvement of tlie ovaries is rare.
Complications and Sequelae. — Of these the cerebral affections
are perha})s the most serious. As already mentioned, there may be de-
lirium aiul liigli fever. In rare instances meningitis has been found.
Hemiplegia and coma may also occur. A majority of the fatal cases are
associated with meningeal symptoms. These, of course, are very rare in
comparison with the frequency of the disease ; yet, in the Index Catalogue,
under this caption, there are six fatal cases mentioned. In some epi-
demics the cerebral complications are much more marked than in others.
Acute mania has occurred, and there are instances on record of insanity
following the disease.
Arthritis is an occasional complication. Albuminuria, with convul-
sions, has been described. Fatal cases have occurred from acute uraemia.
Suppuration of the gland is an extremely rare complication in genuine
idiopathic mumps. Gangrene has occasionally occurred. The special
senses may be seriously involved. ^lany cases of deafness have been de-
scribed in connection with or following mumps. The deafness, unfortu-
nately, may be permanent. Affections of the eye are rare, but atrophy of
the optic nerve has been described.
The diagnosis of the disease is usually easy. The position of the
swelling in front of and below the ear and the elevation of the lobe on the
affected side definitely fix the locality of the swelling. In children in-
flammation of the parotid, apart from ordinary mumps, is excessively rare.
Treatment. — It is well to keep the patient in bed during the height
of the disease. The bow^els should be freely opened, and the patient given
a light liquid diet. No medicine is required unless the fever is high, in
84 SPECIFIC INFECTIOUS DISEASES.
which case aconite may be given. Cold compresses may be placed on the
gland, but children, as a rule, prefer hot applications. A pad of cotton
wadding covered with oiled silk is the best application. Suppuration
is almost nnknown, and need not be dreaded, even though the gland be-
come very tense. Should redness and tenderness develop, leeches may
be used. With delirium and head symptoms the ice-cap may be applied.
In a robust subject, unless the signs of constitutional depression are ex-
treme, a free venesection may do good. For the orchitis, rest, with sup-
port and protection of the swollen gland with cotton-wool, is usually
sufficient.
XI. WHOOPING-COUGH.
Definition. — A specific affection characterised by convulsive cough
and a long-drawn inspiration, during which the " whoop " is produced.
Etiology. — The disease occurs in epidemic form, but sporadic cases
appear in a community from time to time. It is directly contagious from
i^erson to person ; but dwelling-rooms, houses, school-rooms, and other
localities may be infected by a sick child. It is, however, in this way less
infectious than other diseases, and is probably most often taken by direct
contact. The nature of the virus is still doubtful, many organisms hav-
ing been described in the sputum. The observations of Afanassjew in
1887 have been the most satisfactory. He has cultivated a short bacillus,
which grows with well-marked characters, and, when inoculated into the
trachea of animals, produces a catarrhal condition of the mucous mem-
brane. Cornil and Babes * conclude that the organism has not charac-
teristics sufficiently pronounced, or an influence on animals sufficiently
characteristic, to enable us to say that it is specific. Epidemics prevail for
two or three months, usually during the winter and spring, and have a
curious relation to other diseases, often preceding or following measles,
less frequently scarlet fever.
Children between the first and second dentition are commonly affected.
Sucklings are, however, not exempt, and I have seen very severe attacks
in infants under six weeks. It is stated that girls are more subject to the
disease than boys. Adults and old people are sometimes attacked, and in
the aged it may be a very serious affection. Many persons possess immu-
nity against the disease, and, though frequently exposed, escape. Delicate
anaemic children with nasal or bronchial catarrh are more subject to the
disease than others. According to the United States Census Reports, the
disease is more than twice as fatal in the negro race than in others.
Morbid Anatomy. — Whooping-cough itself has no special patho-
logical cliaiigc'S. In fatal cases pulmonary complications, particularly
broncho-pneumonia, are usually present. Collapse and compensatory em-
* Les Bactcries, 1890.
\vih)(»i'iN(j-(:or(iii. 8r>
))hyM(Miiu, vcMiculiir nixl intoi'Htitiul, urr fuiiiHl, ami tho triirlwiil atid bron-
Syiiij)t()inH. ( iilanliiil lunl luiroxyHiiml hIu^'oh ciiii Ix! n'r'o^'iiiz4'<l.
Tlicrt* is u viirml*l(* period of iiiriii)atioii of from m^vcii to Um duvM. In
the nthtrrlidl shnjr tlio cliild lian tlio HViiiptoniH of iiii ordiimry cold,
which limy Ix'ijiii with Hli^dit frvrr, running' jit th(5 now, injection of
tlu^ vyvi^, mill H hronchial coii<^di, UHiiaily dry and Hoint^tiineH \(\\\\\y^ indi-
cations of a spasnindic character. 'IMk^ fever in UHUully not hi^h, und
Hli^dit allciilinn is paid to tlio HyinptoniH, wliiclj aro tliou^dil to !>(• tijow;
of an ordinary cold. After histin^' for a week or ten dayH, inHteiwl
of suhsidini;, the coii^di hcconicH worse and more convnlKive in char-
acter.
'V\\v p(trn.i//sm(f! s/i/(/t\ niai'kcd hy the characteristic; oon^di, dates from
the lirst appeaiancc of the '' whoop." The lit Ijc^inH with a KcrieH of from
lifteen to twenty short cou^^dis of increasing intensity, and then witli a
doop inspiration tiie air is drawn into the lun<^s, making the *' wliooj),"
which may he lieard at a distance^ and frofn which the disease takes its
name. This h)ud ins{)irat()ry sound may sometimes precede the series of
spasmodic expiratory elTorts. Several coughing-fits may succeed each other
until a tenacious mucus is expectorated. This may be small in amount,
but after a series of coughing-lits a considerable quantity may be expec-
torated. Not infrequently it is brouglit up by vomiting or by a combina-
tion of couii^li and regurgitati(^n. There may be only four or five of these
attacks in the day, or in severe cases they may recur every lialf-hour.
During the attack tlie tliorax is very strongly compressed by the powerful
expiratory etforts, and, as very little air passes in through the glottis, there
are signs of defective aeration of the blood ; the face becomes swollen and
congested, the veins are prominent, the eyeballs protrude, and the con-
junctiva3 become deeply engorged. Suffocation indeed seems imminent,
when with a deep crowing inspiration air enters the lungs and the
color is quickly restored. Children are usually terrified at the onset, and
run at once to the mother or nurse to be supported during the attack.
Few diseases are more painful to witness. In severe paroxysms vomiting
is frequent and the sphincters may be opened.
An ulcer under the tonsrue is a verv common event, and was thou2:ht
at one time to be the cause of the disease.
During the attack, if the chest be examined, the resonance is defective
iu the expiratory stage, full and clear during the deep, crowing inspiration ;
but on auscultation during the latter there may be no vesicular murmur
heard, owing to the slow^ness with which the air passes the narrowed glot-
tis. Bronchial rales are occasionally heard.
Among circumstances which precipitate an attack are emotion, such
as crying, and any irritation about the throat. Even the act of swallowing
sometimes seems sutiicient. In a close dusty atmosphere the coughing-
fits are more frequent. After lasting for three or four weeks the attacks
86 SPECIFIC INFECTIOUS DISEASES.
become lighter and finally cease. In cases of ordinary severity the course
of the disease is rarely under six weeks.
The complications and sequelae of whooping-cough are important.
During the extensive venous congestion haemorrhages are very apt to oc-
cur in the form of petechiae, particularly about the forehead, ecchymosis of
the conjunctivae, epistaxis, and occasionally haemoptysis. Haemorrhage
from the bowels is rare. During the paroxysm convulsions may occur,
due perhaps to the extreme engorgement of the cerebral cortex. Very
rarely hemiplegia or monoplegia follows. Sudden death has been caused
by extensive subdural haemorrhage. Whooping-cough must be regarded
as a very unusual cause of cerebral palsy in children. It was associated
with three cases of my series of one hundred and twenty cases, but in
none of them did the hemiplegia come on during the paroxysm, as in a
case reported by S. West.
The persistent vomiting may induce marked anaemia and wasting.
The pulmonary complications which follow whooping-cough are extremely
serious. During the severe coughing-spells interstital emphysema may be
induced, more rarely pneumothorax. I saw one instance in which rupture
occurred, evidently near the root of the lung, and the air passed along the
trachea and reached the subcutaneous tissues of the neck, a condition
which has been known to become general. Broncho-pneumonia, with its
accompanying collapse, is the most frequent pulmonary complication and
carries off a large number of children. It may be simple, but in a consid-
erable proportion of the cases the process is tuberculous. Pleurisy is
sometimes met with and occasionally lobar pneumonia. Enlargement of
the bronchial glands is very common in whooping-cough and has been
thought to cause the disease. It may sometimes be sufficient to produce
dulness upon the manubrium. The heart stands the strain of whooping-
cough remarkably well. During the spasm the radial pulse is small, the
right heart engorged, and during and after the attack the cardiac action is
very much disturbed. It is difficult to determine whether serious damage
ever results. Possibly some of the cases of severe valvular disease in chil-
dren who have had neither rheumatism nor scarlet fever may be attrib-
uted to the terrible heart strain during a prolonged attack of whooping-
cough. Henal complications are very uncommon. Sugar is occasionally
found in the urine.
Diagnosis. — So distinctive is the "whoop" of the disease that the
diagnosis is very easy; "but occasionally there are doubtful cases, particu-
larly during epidemics, in which a series of expiratory coughs occurs with-
out any inspiratory crow.
Prognosis. — Taken with its complications, whooping-cough must be
regarded as a very fatal affection. According to Dolan it ranks third
among the fatal diseases of children in England, where the death-rate
per million from this disease is five thousand annually. The younger
the infant the greater is the probability of serious complications. The
INTM'KNZA. 87
(iiMitliH Hi'o cliirlly lUiioM^ cliililrrii nf lli«< poor uikI iirnoti;^ dclirat'- in
fjUllH.
Treatniont. — I'lirmlH hIiomM l»r wju-iumI of tim mtIoum nutiin) of
wlioopiii;^' «ou;(|j, lln' ^nivity <»f whi(;li in Hcuirroly upprtMriuUMl by i\w
public. rartiiMiliir ciin) mIioiiM Ix^ lukm tlmt (^liildron HUHpiurU^d of the
(iiHOiksc aw not scut to the public mdinols or (exposed in uny wuy iu> tbut
other children ciiii becorni! contjiriiiiuited. There in iiiorc! reprobt'iixiblo
lU'L^lect in connection witli this thiiii with uny oIImt <liH4'ii.s«. Thci niedi-
cinul treiitment of \viioopin|;-c«>u^di is most unsjitisfiictory. Liko otbor
infiH'tions disorders it runs its course pnictically uninliueiuted in :i majority
of cases by dru^^s. In ihe cutiirrhul Hta^je when thcro in fcvor the child
should bi' in bed and a saline fever mixture a<l ministered. If tlu! cou^h is
distri\ssiu;^, i[)ecac.uanha wine and pare<;orii; may be ^iven. For the p;ir-
oxysmal staij^e a suspiciously Ioul^ list of remedies lias been reeommen(b;d,
twenty-two in one po[)ular text-book on therapeutics. If the disease id
due, as seems probable, to a germ growing ui)ou and irritating the bron-
chial mucosa, a germicidal })lan of treatment seems highly rational and
persistent attempts should be made to discover a suitable remedy. (Quinine
phiced upon the tongue; resorcin in one-per-cent solutions, swabbed fre-
quently on the throat; two or three grains of iodoform to an ounce of
starch powder; a spray of carbolic acid — have all been warmly recom-
mended. J. Lewis Smith advises the use of the steam atomizer with a
solution of carbolic acid, chloride of potassium and bromide of potassium
in glycerin, dacobi regards belladonna as the most satisfactory remedy,
lie gives it in full doses, as much as one sixth of a grain of the root or
the extract to a child of six or eight months three times a day. It should
be given in sutiicient doses to produce the cutaneous flush. For the
nervous element in the disease antipyrin has been used with apparent
success.
After the severity of the attack has mitigated and convalescence has
begun, the child should be watched with the greatest care. It is just
at this period that the fatal broncho-pneumonias are apt to develop. The
cough sometimes persists for months and the child remains weak and deli-
cate. Change of air should be tried. Such a patient should be fed with
care, and given tonics and cod-liver oil.
XII. INFLUENZA {La Grippe).
Definition. — An infectious disease characterised by great prostration
and often catarrh of the mucous membranes, particularly the respiratory
and gastro-iutestinal. There is a marked liability to serious complications,
particularly pneumonia.
Epidemics appear at intervals and spread with extraordinary rapidity,
so that in a few weeks an entire continent mav be involved. The dis-
7
88 SPECIFIC INFECTIOUS DISEASES.
ease has been known for several centuries, and there have been within
the past fifty years several extensive outbreaks, notably those of 1833,
1847-'48, and the recent outbreak in 1889-'90. Many of the epidemics
have started in Russia, hence the name Russian fever. In October of
1889 it prevailed extensively in St. Petersburg. During November and
December it spread to Germany, France, and western Europe, appearing
in London about the end of December. Cases appeared in this country
about Christmas, and the disease rapidly became epidemic.
Etiology. — The conditions which favor its development and rapid
spread are unknown, and the exhaustive literature of the past year has
not brought us nearer a solution of the problem. It appears to be in-
dependent of meteorological conditions. While some authorities hold
that the affection is due to a miasmatic material in the atmosphere, others
probably more correctly hold that it is due to a specific virus of the
most intense infectiveness. Like other rapidly spreading diseases, it is
conveyed along lines of travel. The bacteriological examinations which
have been made in large numbers of cases leave us still in doubt, and the
varied character of the germs found by reliable observers indicates that
the true virus has not yet been detected. The pus organisms and the
diplococcus pneumonice have been found oftenest, but these are wide-
spread organisms and are probably not associated in a causative manner
with the disease.
Morbid Anatomy. — Uncomplicated cases recover. In the delicate
and aged alone do we see fatal results, and then only from the intensity
of the fever or the profound depression. Injection and swelling of the
pharyngeal and laryngeal mucosa, bronchitis, and a catarrhal condition of
the stomach and intestines may be present.
The complications are very varied. Severe bronchitis, lobar and lobu-
lar pneumonia, and nephritis may exist.
S3miptOins. — In many cases the attack closely resembles an ordinary
catarrh with slight fever, dryness and swelling of the nasal mucosa, and
then increase in the secretion. In the severer cases the coryza is sub-
sidiary or absent, and the symptoms are those of an infection of varying
grades of severity. A striking feature is the severe nervous manifestation
at the outset, the headache, pain in the back and legs, and a general sore-
ness as if bruised or beaten. With the exception of dengue and small-pox
there is no affection in which these symptoms are more pronounced. De-
lirium may be marked. Associated with these is a prostration and cardiac
weakness out of proportion to the intensity of the fever, and sometimes
very alarming. The pulse is feeble, small, and intermittent. Death may
result directly from heart-failure, as in cases mentioned by Wilks.
Serious nervous complications are marked delirium and meningitis^
the latter usually in association with pneumonia. Bristowe has reported
several cases of abscess of the brain following influenza. Peripheral neu-
ritis was not very uncommon in the last epidemic. Mental disorders are
INKi.rKNZA. 80
not infnMjiM»nt. Iimptiluflr for mrntiil nxiTtinn, «lrpn*Hxi<)ri of i4|MriU, ivm
insiinily, iniiy f<»ll'>\v an ill lark.
AlT»M'lit>iiM of (lu^ respiratory nr^'arm arc tin* rnoMt wrioim. Many '-jimi'H
prcMciit an iiitiMim^ hronrhitis^ iiivoKiii^ tlio larpi aiwl Hrnall IiiIm-h and
corniii^ on with hi^li fuvcr, Hornet irnrn with delirinin. An intenH4! general
l)iniichitiM was coinmnn dnrin;^ tlie recent cpiflcniic!. In children it niiiy
hu complicated witli hron(!ho-pn<'iirnonia. By far tlie most wriouH and
fatal complication is pnvutnotiiit, which may follow th(! hronchitiH, or w;t
in with well-characterised symptoniH. SometimcH the Bymptoms may ut
first he ohscur(» and the pneumonia atypical. Tims, after an initial ri^^or,
witii some (Ivspuiea and liiLrli fever, tho local si^^ns may be ohscuro and it
may not ho until the third or fourth day, or even later, that the physical
sii^ns of a ])ueumonia are (h»teete<l. The sputa may not he rusty until the
ft)urth or lifth day. The crisis may he deferred or the defervescence may
ho by lysis. A considerable proportion of the cases, however, run a normal
course. So far as I could see, there was nothing special or peculiar in the
pneumonia; all the anomalies which have been mentioned as occurring in
inthienza are found in any largo series of cases. Abscess of the lung may
follow. Pleurisy is not an uncommon complication, and empyema may
dovelo}).
The gastro-intestinal symptoms may be marked ; thus, with the initial
fever, there may bo nausea and vomiting. Diarrluea is not uncommon;
indeed, the brunt of the catarrhal process may fall upon the gastro-intes-
tinal mucosa.
The diagnosis of the disease offers no difficulties when it occurs in epi-
demic form. Coryza is not always present, and the symptoms may be
those of general fever with great prostration. In other instances the bron-
chitis may be an important feature. The severe prostration, fever, de-
lirium, with the initial bronchitis, and occasionally epistaxis, may lead to
the diagnosis of typhoid fever. The complications are, as a rule, readily
recognised, though at first the symptoms of the pneumonia may be some-
what indefinite.
Treatment. — In every case the disease should be regarded as serious,
and the patient should be confined to bed until the fever has completely
disappeared. In this way alone can serious complications be avoided.
From the outset the treatment should be supporting, and the patient
should be carefully fed and well nursed. The bowels should be opened
by a dose of calomel or a saline draught. At night ten grains of Dover's
powder may be given. At the onset a warm bath is sometimes grateful in
relieving the pain in the back and limbs, but great care should be taken
to have the bed well warmed, and the patient should be given after it a
drink of hot lemonade. If the fever is high and there is delirium, small
doses of antipyrin may be given and an ice-cap applied to the head. The
medicinal antipyretics should be used with caution, as profound prostra-
tion sometimes develops iu these cases. Too much stress should not be
90 SPECIFIC INFECTIOUS DISEASES.
laid upon the mental features. Delirium may be marked even with slight
fever. In the cases with great cardiac weakness stimulants should be
given freely, and during convalescence strychnia in full doses.
The intense bronchitis, pneumonia, and other complications should
receive their appropriate treatment. The convalescence requires careful
management, and it may be weeks or months before the patient is restored
to full health. A good nutritious diet, change of air, and pleasant sur-
roundings are essential. The depression of spirits following this disease is
one of its most unpleasant and obstinate features.
XIII. DENGUE.
Definition. — An acute infectious disease of tropical and subtropical
regions, characterised by febrile paroxysms, pains in the joints and mus-
cles, and sometimes a cutaneous rash.
The disease was first noted in Java toward the close of the last cent-
ury, and it was probably described by Kush in 1780. During this century
many epidemics of it have been reported, particularly in India, Africa,
and the southern United States. S. H. Dickson gave the most satisfac-
tory account of the disease as it appeared in Charleston in 1828. Since that
time there have been three or four wide-spread epidemics, confined chiefly
to the Gulf States and rarely extending beyond the 32nd parallel.
Etiology. — Many observers regard it as contagious, and Dickson
mentions in the history of his own household that during the epi-
demic of 1828 all were attacked, whereas in the epidemic of 1850 he
and the cook (the only ones remaining in his household of those who
composed it in 1828) alone escaped. The question can scarcely yet be
considered settled. The disease spreads from place to place, and is con-
veyed by ships and along railroads. It is remarkable among epidemics as
practically affecting all members in a community who have not been pro-
tected by a previous attack. Matas, in his excellent account,* states that
one attack does not protect from subsequent infection. It attacks all
races equally. The disease is stated to attack animals.
McLoughlin, of Texas, has found in the blood of patients a micro-
coccus, which he regards as the special agent and has been able to
cultivate. The slides which he kindly sent me show a streptococcus-like
organism, but it is impossible yet to speak definitely as to the relations
which it bears to the disease. If it be true that animals are subject to the
affection, tlie subject could be conclusively worked out during the next
epidemic. Some writers have held that dengue is only a modified form
of yellow fever. It has in some instances preceded the development of
this disease.
* Keating's Encyclopedia of Diseases of Children, vol. i.
DKNdlTK. 91
Am tlin (liMruHti in iirvrr fiihil, iin nliMrrv(itir)riH liiivc* }}GOfi miulit iij)on itjt
ptilliolo^^noil aiiiitoiny.
Syin])toinB. 'rii** jmtkmI of iiicul)at.iofj in from tlir««- \n (Ivo davH,
(luriii;^ wliitli llu' [lalnni frriM well. Tin- uttark wIh in Muddirnly with
lu«ji(lii('lu», cliilly f(M'lin;^'s, umi irilcHHo ucliiii;,' puiiiH in the jointn iind rnuu-
cIcM. 'V\w fever ris«'H ^'nidimlly und nuiy rracli as liij^'h um H»<;'' or 107".
'rill' pulse ia nipifl ami (liere are tln^ other phenomena a>4M(»eiate<l with
acute fever — loss of appetite^ eoated tongue, Hli;^'iit nocturnal delirium, and
conct'iitraled iiiiiic. In (lie initial Hta^'i^ there nuiy he an erythematouH
rusli. hi a majority of the caHes tlie pains in tlie muscleH, joints and bonen
are of a most aLr;j:ravated character, and the patients speak of them im of a
horiuLT or hrcakini,' cliaracter, heiu^o tlie popuhir nanu; '' hreak-hone fever.'*
Tile lar^e and small joints are atTe('tc(l, sometimes in succes-sion, and tliey
bocomo swollen, reil, and painful. The pains shift about, and in some
cases cutaneous hyporuvsthesia has been noted. In some iuRtances there is
a tendency to liaMnorrhaLjc, frotn either the nose, lun^s, stomach, or bow-
els. Kuu^eno Foster speaks of havini; seen black vomit, similar to that of
yellow fever, and in three instances alarmin<( ha'inorrha^e from the bow-
els, which in one case persisted for three months and caused death.
The fever o^radually reaches its height by the third or fourth day, and
the })atient enters upon the apyretic period, which may last from two to
four days, and in which he feels prostrated and stiff. At this time, in a
largo number of cases, an eruption is common wliich, judging from the
description, has nothing distinctive, being at times macular, like measles,
at others, ditTuse and scarlatiniform, or papular, or lichen-like. In other
instances the rash has been described as urticarial, or even vesicular. A
second paroxysm of fever then occurs, and the pains return. Certain
writers describe inflammation and hyperaemia of the mucous membrane
of the nose, mouth, and pharynx. Enlargement of the lymph-glands
is not uncommon, and may persist for weeks after the disappearance
of the fever. Convalescence is often protracted, and there is a degree of
mental and physical prostration out of all proportion to the severity of
the primary attack. By far the most distressing symptom is the pain,
which all who have experienced the disease speak of as agonising and in-
tolerable, and more severe than that experienced in any other acute fever.
Complications are rare. Insomnia and occasionally delirium, resem-
bling somewhat the alcoholic form, have been observed. A relapse may
occur even as late as two weeks. Briefly, the course of the disease may be
described as consisting of a febrile paroxysm of three or four days ; a re-
mission of variable duration, which may be wanting ; and a second parox-
ysm of about three days. The average duration of a moderate attack is
from seven to eight days.
The diag)wsis of the disease rarely offers any special difficulties, pre-
vailing as it does in epidemic form, and attacking all classes indiscrimi-
natelv. Isolated cases mis^ht be mistaken at first for acute rheumatism.
92 SPECIFIC INFECTIOUS DISEASES.
Southern physicians say that occasionally yellow fever and dengue may
be confounded.
Treatment. — This is entirely symptomatic. Quinine is stated to be
a prophylactic, but on insufficient grounds. Hydrotherapy may be em-
ployed to reduce the fever. The salicylates or antipyrin may be tried for
the pains, which usually, however, require opium. During convalescence
iodide of potassium is recommended for the arthritic pains, and tonics
are indicated.
XIV. CEREBRO-SPINAL MENINGITIS.
Definition. — A specific infectious disease, occurring sporadically and
in epidemics, characterised by inflammation of the cerebro-spinal menin-
ges and a clinical course of great irregularity.
The affection is known by the names of malignant purpuric fever,
petechial fever, and spotted fever.
Etiology. — Since its recognition in Geneva in the early part of this
century, numerous epidemics have been described in Europe and in
America, the full details of which are to be found in Stille's elaborate
article.* In Europe it is remarkable with what frequency the disease
has occurred in garrisons. In this country the disease was first seen in
Massachusetts in 1806, since which date there have been epidemics in vari-
ous localities at irregular intervals.
During the civil war, according to Smart's report, comparatively few
deaths were caused by this disease.
Sporadic cases occur from time to time in the larger cities and country
districts on this continent. After the first epidemic in Montreal in 1873
occasional cases occurred. In Philadelphia, since its appearance in 1863,
there have been cases reported every year in the mortality bills. Without
autopsy the diagnosis of many of these cases is extremely doubtful ; but
there can be no question that the disease, though rare, still lingers. Judg-
ing from my own experience in three of the hospitals of that city, and
from the fact that in five years I saw only three instances, I would regard
it as very much less frequent than the reports of the Health Office would
seem to indicate.
The disease has broken out simultaneously in regions far distant from
each other.
The epidemics have occurred most frequently in winter and spring.
Neither soil nor locality has any special influence. The concentration of
individuals, as in large barracks, seems to be specially favorable.
Children are much more susceptible to the disease than adults, though
the susceptibility has differed in different epidemics. In certain places
* System of Medicine, Philadelphia, vol. i, 1885.
CIIItliHKo SIMNAL MKNINCilTIS. 93
cliildrni tiloiio liiuc lircii ul1t'r|r<| ; in nllirrri tiiii (liik*tuu) Iiuh Ixtii chiefly
utn()i)|( tidiills. It iillurkH iimlcM iiml fiMiiilrM iiliko.
('(U'tuin cpidciiiicH luivd Ihm'M iiiohI pniviilciit in country iliMtricU. In
1H7.'{ tlu^ (lis(MiH(^ |it'<^viiil('<i ul(Mi^' IImi vallry <*f tho OttuwUf in villu|^M>H und
comiliv jtluccs, niiuli ni(»rt5 Hcvcrcly lluiii in tliu ciiirH of Montn^ul and
OLIuwu.
( )\('i*-r\( rl Kill, j»rol(in;^n'd nmrchin;^^ in tin* licat, <lrj)rcHHin^ nurntul or
iMxlily siin(niii(liii;^'s, ami the nMHiTy an<l H<jiuilor <if tlio lar^o tcncment-
honst's in cities uro prt'dinpoHin^ cunHt'H.
Tlio disease is not directly conta^dons ; ii is j)rol)al)iy not iran-inniied
by elotliin^' or the excretions.
'I'lje nature of tl»e virus is as yet unknown, in the nu^ningeul exuda-
tion then' is nou found in many caseH the laiice-Hhaj)cd coccub, Kiniilar in
all respects to the pminnococcus. In other iuHtances tliin microbe hafi
been associated with the ordiiuiry ])us orpmisnis. Cornil and Habes con-
clndo that cerehro-spinal nu'nin<^itis nuiy l)o caused !)y Hcvcral dilTerent,
often associated, forms of nncro-or<j^anisnis, of which tlic lance-shaped
coccus of Pasteur is the most common.
Morbid Anatomy. — In nudi<j^nant cases there maybe no charac-
teristic cliani^cs, for the patient may die before exudation occurs. In well-
nnirked cases tlie meninges of the brain and cord are inflamed. Tlie fol-
lowiuij^ abstract of one of the Montreal cases, in wliicli death occurred
about the liftli day, gives a good idea of the condition in this disease : The
brain contained an excessive amount of blood. The dural sinuses and all
the veins and arteries were engorged. Some of the veins of the pia were
as largo as goose-quills. On the cortex there was much lymph beneath
the arachnoid on either side of the longitudinal fissure — more on the right
than on the left hemisphere. At the base there was a purulent exudate
about the chiasma and inner parts of the Sylvian fissure, but none on the
pons or medulla. There was no lymph in the course of the middle cere-
bral arteries. The ventricles contained serous exudate ; the walls were
not softened. The gray matter of the brain was deeply congested, but
presented neither haemorrhages, spots, nor softening. In the spinal cord
the veins of the pia were engorged. On the posterior surface, from the
cervical enlargement to the cauda equina, was a thick layer of grayish-
yellowy lympho-purulent exudation, which in places produced irregular
bulging of the arachnoid membrane. There were no changes in the tho-
racic or abdominal viscera. This picture corresponds closely with that
presented by five other cases which I have examined. In one case, how-
ever, the amount of exudation on the hemispheres was large, and the con-
volutions were covered with a thick creamy pus. Foci of haemorrhage
and of encephalitis occur in some cases. The formation of abscess has
been occasionally described. The involvement of the ventricles is less
than in tuberculous meningitis. In the cases which I have seen the exu-
dation, as is usual in the secondary meningeal inflammations, was most
91 SPECIFIC INFECTIOUS DISEASES.
abundant on the cortex. The exudation may extend along the lymph-
sheaths of the cranial nerves, particularly the auditory and optic. In
long-standing cases the inflammatory processes appear more chronic.
There are thickening and adhesion of the membranes, areas of cortical
softening or of atrophy, and, in some instances, hydrocephalus. The
changes in the other organs are those associated with fever. In the ma-
lignant cases there may be hsemorrhages into the skin and on the serous
membranes. Pneumonia, pleurisy, endocarditis, dysentery and nephritis
have been described. The spleen varies in size according to the period
of the disease at which death has Occurred. When the fever has been
intense it is enlarged.
Symptoms. — Cases differ remarkably in their characters. Many
different forms have been described. These are perhaps best grouped into
three classes :
1. Malignant Form. — This fulminant or apoplectic type occurs with
variable frequency in epidemics. It may occur sporadically. The onset
is sudden, usually with violent chills, headache, somnolence, spasms in the
muscles, great depression, moderate elevation of temperature, and feeble
pulse, which may fall to fifty or sixty in the minute. Usually a purpuric
rash develops. In a Philadelphia case in 1888 a young girl, apparently
quite well, died within twenty hours of this form. There are cases on
record in which death has occurred within a shorter time. Stille tells of
a child of five years, in whom death occurred after an illness of ten hours;
and refers to a case reported by Gordon, in which the entire duration of
the illness was only five hours.
2. Ordinary Form. — The stage of incubation is not known. The dis-
ease usually sets in suddenly. There may be premonitory symptoms :
headache, pains in the back, and loss of appetite. More commonly, the
onset is with headache, severe chill, and vomiting. The temperature rises
to 101° or 102°. The pulse is full and strong. An early and important
symptom is a painful stiffness of the muscles of the neck. The headache
increases, and there are photophobia and great sensitiveness to noises.
Children become very irritable and restless. In severe cases the contrac-
tion of the muscles of the neck sets in early, the head is drawn back, and,
when the muscles of the back are also involved, there is opisthotonos.
The pains in the back and in the limbs may be very severe. The motor
symptoms are most characteristic. Tremor of the muscles may be pres-
ent, with tonic or clonic spasms in the arms or legs. Rigidity of the
muscles of the back or neck is very common, and the patient lies
with the body stiff and the head drawn so far back that the occiput
may be between tlie shoulder-blades. Except in early childhood con-
vulsions are not common. Strabismus is a frequent and important
symptom. Spasm of the muscles of the face may also occur. Cases
have been described in which the general rigidity and stiffness was such
that the body could be moved like a statue. Paralysis of the trunk mus-
cr.KKIiKo SFMNAL MKNIN({ITI.S. 95
cloH in riirc, Iml luinilyNiH of tlin iihihcIih of tin* <*yo Hri(i tin? tiuiu in not un-
cnlMlllotl.
Of Hoiisory HyiiiptoiiiH, In'miiiciir iri IIm^ iiiomI doniijiuiit uixl |M'niiMtii
from tlui outset. It JH cliictly in I lie Imrk of tlir IiimuI, mikI i\w puiii 4'X-
tcixiM into tile iH'ck iiiul hack. 'I'licn* nmy Ix' ^^rcut M'riHitiviMK.'M uloti^
the Hpinr, iiiul in iiiiiiiy i'uhvh tlicro Ih tinirkrd hypcrifHthcHiu.
'IMio pHychicjil HyrnptoiiiM iirc nuiiked. Dchriiiin ocnurH ut the oiitM;t,
(HHMiKionally of u furious and inaiiiac^il kind. The patient may (liHpUy
marked orotic HyiiiptoiiiM. 'I'lie (h'liriuni ^ivcH phice in a few duyH to Htii-
por, winch, as tlie ctTusion increases, deepens to coma.
'i'lie temperaturo is irrep^uhir and varial)h'. Remissions occur fre-
(pioiitly, aiul there is no uniform or typi«'al curve during tlie disease. In
some instances tlu're luis heen lilth' or no feycr. In other ca8C8 the tem-
peraturo may reach I(»r> or Hxi , or, hefore (h'atli, UiH". 'Vhc pulwi may
ho very rapid in children; in adults it is at first usually full and strong.
In some eases it is retnarkahly slow, and may not hv more than fifty or
sixty in the minute. Si«^hing respirations and Cheyne-Stokes hreathin^'
are met with in some instances. Uidess there is j)neumonia the respira-
tions are not often inereased in frequency.
The eutaneons symptoms of the disease are important. Herpes labia-
lis occurs with even greater frequency than in pneumonia or in inter-
mittent fever. The })etechial rash, which has given the name spotted
fever to the disease, is very variable. Stille states that of ninety-eight
cases in the Philadelphia Hospital, no eruption was observed in thirty-
seven. In the Montreal cases petecliiifi and purple spots were common.
They appear to have been more frequent in the epidemics on this conti-
nent than in Europe. The petechiaB may be numerous and cover the
entire skin. An erythema or dusky mottling may be present. In some
instances tliere have been rose-colored hypera?mic spots like the typhoid
rash. Urticaria or erythema nodosum, ecthyma, pemphigus and in rare
instances gangrene of the skin have been noted.
As already stated, vomiting may be a special feature at the outset ; but,
as a rule, it gradually subsides. In some instances, however, it persists
and becomes the most serious and distressing of the symptoms. Diarrhcea
is not common. The bowels are usually confined. The abdomen is not
tender. In acute cases the spleen is usually enlarged.
The urine is sometimes albuminous and the quantity may be increased.
Glycosuria has been noted in some instances, and in the malignant forms
lijematuria.
The course of the disease is extremely variable. Hirscli rightly states
that it may range between a few hours and several months. ^lore than
half of the deaths occur within the first five davs. In favorable cases,
after the symptoms have persisted for five or six days, improvement is in-
dicated by a lessening of the spasm, reduction of the fever, and a return
of the intelligence. Sudden fall in the temperature is of bad omen. Con-
96 SPECIFIC INFECTIOUS DISEASES.
valescence is extremely tedious, and may be interrupted by complications
and sequelae to be noted.
3. Anomalous Forms.
(a) Abortive 2'ype. — The attack sets in with great severity, but in a
day or two the symptoms subside and convalescence is rapid. Striimpell
would distinguish between this abortive variety, which sets in with such
intensity, and the mild ambulant cases described by certain writers. He
reports a case in which the meningeal symptoms set in with the greatest
intensity and persisted for four days, the temperature rising to 40*9° C.
On the fifth day the patient entered upon a rapid and satisfactory con-
valescence. In the mild cases, as distinguished from the abortive, the pa-
tients complain of headache, nausea, sensations in the back and limbs, and
stiffness in the neck. There is little or no fever, and only moderate
vomiting. These cases have been met with, and could be recognised only
during the prevalence of an epidemic.
{b) An intermittent type has been observed in many epidemics, and is
recognised by von Ziemssen and Stille. It is characterised by exacerba-
tions of fever, which may recur daily or every second day, or follow a curve
of an intermittent or remittent character. The pyrexia resembles that of
pyaemia rather than malaria.
(c) Chronic Form. — Heubner states that this is a relatively frequent
form, though it does not seem to be recognised by many writers on the
subject. An attack may be protracted for from two to five or even six
months, and may cause the most intense marasmus. The attack consists
of a series of recurrences of the fever, and may present the most complex
symptomatology. It is not improbable that these protracted cases depend
upon chronic hydrocephalus or abscesses of the brain. This form differs
distinctly from the intermittent type. A very remarkable instance of it
is described by Worthington,* in which the disease lasted for fourteen
weeks.
Complications. — Pleurisy and pericarditis are not uncommon.
Pneumonia is described as frequent in certain epidemics. Immer-
mann found, during the Erlangen epidemic, many instances of the com-
bination of pneumonia with meningitis, but it does not seem possible to
determine whether, in such instances, pneumonia is the primary disease
and the meningitis secondary, or vice versa. The frequency with which
inflammation of the meninges of the brain complicates pneumonia has
already been mentioned. It is not impossible that the pneumococcus is
responsible for both affections. Arthritis has been the most frequent
complication in certain epidemics. Many joints are affected simulta-
neously, and there are swelling, pain, and exudation, sometimes serous,
sometimes purulent. This was first observed by James Jackson, Sr., in
the epidemic which he described.
* Canada Medical and Surgical Journal, vol. xiv.
rKKKHKO-SPINAIi MKNINCillLs. 97
Aliioii^ the important mM|lirlti; ui'n tlioM) tilTiH'tiit^ ihu li|>c<:ud MDiet.
lUiiKliirMH iMiiy rcHiilt from optic nniritiH with atrophy. KtTutitiif with
uliiorution inay th'vclop. Thin iiiuy uImo occur in Llic iiM-'iiingitiH following
piHMiinoiiia. Iritis in \vha ('(tMiiiioii.
Still iiiom srrious uii' i\ni «'iir KvmptomH, purtiruhirly in children.
DoufncHs very ofU'it follows inthiiiiniutioii of the hihyrinth ; the rcMult, no
doubt, of the direct extension of the iiitluninnition ulon^ the auditory norvo.
In children this not infrr<|iiriitly leads to deuf-inutisni. Won ZicniHiien
HttitoH that ill the deaf and dinnh institutions of IhindxT^und Nuremberg,
in 1874, almost all the pupils hail heconie deuf from epidemic cerebro-
s{)iiuil menin;^Mtis.
lleatlaehe may persist for months or years after an attack. Chronic
hydrocephalus develops in certain instances in cluldren. The BymptomH
of this arc '' |)aroxysms of bevere headache, ])ains in the neck and ex-
tremities, vomiting, loss of consciousness, convulsions, ami involuntary
discharges of ficces and urine " (von Zicmssen). Von Ziemssen regards
chronic hydrocephalus as by no means a rare sequela. Mental feebleness
and ai)hasia have occasionally been noted.
Paralysis of inilividual cranial nerves or of the lower extremities may
persist for some time. In some of these cases unquestionably there may
bo peripheral neuritis, as Mills suggested.
Diagnosis. — There are several alTections with which cerebro-s])inal
meningitis is likely to be confounded :
(u) Tuberculous Meni)igitis. — In sporadic cases it is sometimes impos-
sible to determine the nature of a case in the absence of local tuberculous
disease, detraction of the neck and spasms of the muscles of the arms
and legs are not nearly so marked and prominent in tuberculous menin-
gitis. Herpes also is rare, and the pulse is more irregular. There is rarely
petechial eruption. "When the disease is prevailing epidemically this fac-
tor is of the greatest help in the diagnosis.
(/;) Pneumonia. — The meningeal complication of tliis disease is most
commonly confined to the cerebrum. As the cortex is chiefly involved,
there may be a good deal of motor spasm and tremor, but rarely is there
retraction of the muscles of the neck or opisthotonos. In sporadic cases,
as has been said, it may be quite impossible to decide "whether the pneu-
monia has complicated the meningitis or the meningitis the pulmonary
affection. The bacteriological examination gives no clue, as the pneumo-
coccus is found in both situations.
(c) With other Acute Infectious Diseases. — Both typhus and typhoid
present symptoms which closely simulate cerebro-spinal meningitis. On
several occasions at the Montreal General Hospital cases have been sent
into the ward with the diagnosis of cerebro-spinal fever. These cases
showed high fever, delirium, retraction of the neck, spasm, and tremor of
the muscles, and had not the post-mortem examination revealed typhoid
lesions and only cerebro-spinal congestion the diagnosis would not have
98 SPECIFIC INFECTIOUS DISEASES.
been corrected. I am sure that many of the cases sent into the health offices
as cerebro-spinal fever are instances of the cerebral form of typhoid.
I have already referred to the fact that the malignant form of small-
pox may be mistaken for cerebro-spinal meningitis.
It could scarcely be possible to confound tetanus with this disease.
Prognosis. — ITirsch states that the mortality has ranged in various
epidemics from 20 to 75 per cent. In children the death-rate is much
higher than in adults. Cases with deep coma, repeated convulsions, and
high fever rarely recover. The outlook in the protracted cases is not
good, though Heubner gives an instance of a lad of seven, who was ill
from the end of February until the end of June, with repeated recur-
rences, was worn to a skeleton, and yet completely recovered.
Treatment. — The higli rate of mortality which has existed in most
epidemics indicates the futility of the various therapeutical agents which
have been recommended. When we consider the nature of the local dis-
ease and the fact that, so far as we know, simple or tuberculous cerebro-
spinal meningitis is invariably fatal, we may wonder rather that recovery
follows in any well-developed case.
In strong robust patients the local abstraction of blood by wet cups
on the nape of the neck relieves the pain. General bloodletting is rarely
indicated. Cold to the head and spine, which was used in the first epi-
demics by New England physicians, is of great service. A bladder of ice
to the head, or an ice-cap, and the spinal ice-bag may be continuously em-
ployed. The latter is very beneficial. Judging from the beneficial effects
of the general bath in typhoid with pronounced cerebro-spinal symptoms,
hydrotherapy should be systematically employed if the temperature is
above 102^°. In private practice the cold-pack or sponging may be sub-
stituted. If any counter-irritation is thought necessary, the skin of the
back of the neck may be lightly touched with the Paquelin thermo-
cautery. Blisters, which have been used so much, are of doubtful benefit
and should not be employed. Of internal remedies opium may be given
freely, best as morphia hypodermically. Stille recommends either a grain
of opium every hour in severe cases or every two hours in cases of mod-
erate severity ; von Ziemssen advises the hypodermic of morphia, from
one third to one half grain in adults. Mercury has no special influence
on meningeal inflammation. Iodide of potassium is warmly recom-
mended by some writers. Quinine in large doses, ergot, belladonna
and Calabar bean have had advocates. Bromide of potassium may be
employed in the milder cases, but it is not so useful as morphia to control
the spasms.
The diet should bo nutritious, consisting of milk and strong broths
wliile tlie fever persists, ^fany cases are very difficult to feed, and Heub-
ner recommends forced alimentation with the stomach-tube. These cases
seem to bear stimulants well, and whisky or brandy may be given freely
wlien there are signs of a failing heart.
Dim riii.iiiA. ^
XV. DIPHTHERIA.
Doflnltion. — A himmmHc infrctiojiH disriim*, clmnwrU^rizcMl by a lr>oaI
ri))riii<Mis cxinliito, iiHually ii|)(»ii a iiiiKroiiH Tiimiliniiu*, tiii<l l>y roriMtittitioiiul
Hymj)t(miH of vuryin;^ iiitniHity. 'i'ho jin'Mciicu of tliu KlrhH-I/wHlcrr hiioil-
liiH miiy \w n';^'ar(l('(l um (Ih» ctiolo^'icjil criterion hy wliidi true? (li[)htlH;ri:i
iimv !>•* (list iiii^'iiisli(Ml from other forins of psrinlo-nirrnhrjiiiouM iuflamrnu-
(ioii.
Historical Note. 'I'hr (liscasc wum known to AretnMiH ami (iiih-n.
Mj)i(li»rni('s occmrrd iliroiii^dioiit tlic niidillf a^(»H. It apiwarcMl early
niuoii«j; tlie settlors of Nrw Kn«^'lari(l, and accountH uro oxtunt of epidemica
in tliis country in the scvcntccntli and ci;^ditccnth centuries. Iluxliam
and Fotheru^ill i^nw exeelh'nt descriptions of tht; (liMeaso. An adniirahlo
account was «j;iven hy Samuel Hard,* (if Now York, in 1770, wlio.sc cMsuy
is ouo of the most solid contrihutioiui made to medicine in America. It
was reserved for Pierro Bretonneau, of Tours, to grasp the fact that
anfjina suffortttini, ^' I'tjHanchr ///r/////;/^/," the" j)utrid "and otlior form.s of
maliu^nant sore throat were one and the same disease, to which lie gave
the name " diphth(''rite."
Etiology. — The disease is endemic in tlie larger centres of po])ula-
tion, and becomes epidemic at certain seasons of the year. It is a re-
markable fact that while other contagious diseases have diminished within
the past decade, diphtheria, particularly in cities, has increased. It is by
no means confined to the poorer districts, but occurs in the houses of the
better classes, particularly when the plumbing is defective. The disease
is, however, not conlined to cities. It has prevailed with great severity
in country districts, in which indeed the affection seems to be specially
virulent. The relation between imjierfect drainage and the diphtheria
poison has not yet been satisfactorily determined. Perhaps, as Thorne
suggests, the faulty conditions produce sore throat of a benign character,
which, as in scarlet fever, affords a soil suitable for inoculation by the
diphtheria germ, when present in the air. Drains, too, he thinks may
retain the virus received through the sputa and dejecta of the sick. This
author states that no prevalence of diphtheria has ever been definitely
traced to polluted water.
Diphtheria is a highly contagious disease, readily communicated from
person to person. The poison is given off in the pharyngeal secretion
and in the saliva, but not in the breath. Xo disease of temperate regions
proves more fatal to physicians and nurses. There seems to be particular
danger in the examination and swabbing of the throat, for in the gagging,
coughing, and. spluttering efforts the patient may cough mucus and flakes
of membrane into the physician's face. The virus attaches itself to the
clothing, the bedding, and the room in which the patient has lived, and
* Transactions of the American Philosophical Society, vol. i, Philadelphia, 1770.
100 SPECIFIC INFECTIOUS DISEASES.
lias, in many instances, displayed great tenacity. The disease may be
transmitted by inoculation. The contagion does not seem to be widely
diffused in the neighborhood of the patient. At the Montreal General
Hospital we rarely had cases develop in the wards adjacent to those in
which there were diphtheria patients.
There is a wide-spread belief in the profession that the disease may be
communicated from animals. There is in calves a contagious pseudo-
membranous affection which is said to be communicable to man. Cows
are not known to be affected spontaneously. In the epidemics in which
the contagion has been traced to the milk, it is more probable that the
virus has been accidentally mixed with it than that the cows were them-
selves diseased. Cats are subject to a pseudo-membranous disease, and
there are many cases on record in which children appear to have caught
diphtheria from them. On the other hand, I know of one case in which
a cat died of angina and intense pseudo-membranous colitis, and the chil-
dren who nursed it did not take the disease ; and of a second case, in
which a pet cat had coryza, difficult breathing, fever, and enlarged cervi-
cal glands, and here too the children were not affected. The so-called
diphtheria of fowls is apparently not associated with the same germ as the
human diphtheria.
Of predisposing causes age is one of the most important. Very young
children are rarely attacked, but Jacobi states that he has seen three in-
stances of the disease in the newly born. Between the third and the fif-
teenth year a large majority of the cases occur. In this period the great-
est number of deaths is between the second and the fifth years. Girls are
attacked in larger numbers than boys, probably because they are brought
into closer contact with the sick. Adults are frequently affected. The
disease is most prevalent in the cold autumn weather.
Caille regards as special predisposing elements in children, enlarged
tonsils, chronic naso-pharyngeal catarrh, carious teeth, and an unhealthy
condition of the mucous membrane of the mouth and throat.
Epidemics vary in intensity. While in some the affection is mild and
rarely fatal, in others it is characterized by wide extension of the mem-
brane, and shows a special tendency to attack the larynx.
The Specific Germ. — The bacillus originally described by Klebs and
more thoroughly studied by Loeffler appears to be the specific virus. It
is found in the pseudo-membranes, not in the subjacent mucosa, or in the
blood, or in the internal organs. It is a non-motile bacillus, varying from
2-5 to 3 j[/ in length, and from 0*5 to 0*8 /u, in thickness. It appears as a
straight or slightly bent rod with rounded ends. Irregular bizarre forms,
such as rods with one or both ends swollen, are, however, not uncommon.
The bacillus stains in sections or cover-glass specimens by Gram's method.
It is best cultivated on blood serum and bouillon. The colonies are large,
elevated, grayish-white, with an opaque centre. Welch and Abbott also
state that it grows well on potato ; but the growth is invisible or indicated
hinrniKKiA. lOl
only liy ii dry liiiii ^Hu/,(<. It iiitil(i|>lirH rmilily in milk. Althoiij^li it
foriMH no HporcM, it in ii wry {M^rHiMlcnl, biirilhiM, imil ciiltiin'M huvo Ih'ch
inii(l(' fioin intMiliianr prt'Hcrvrd fm- live riiontliH in ii dry rlolh. TIhj
ciiltun'M iiKHulalrd into tlic tni(')i<*H of aninnilM pnMlMcu li wcll-niurkcd
diplitlirritic cxndiilinn with dcvrlopnicnt of tlic l>a<'illi und fU'^'oiidnrv in-
V(»lv(>in('nl (»f the l\ inpl»-;^liindH, in wliicli n-rnjirkiihlr in'crotir iiri'iiH rxTiir,
with fni^Mncntatidti of th(' nthdci (l-'lrxncr). Hrij'p-r und Kriink«d liavo
separated from tlic ndliins a tox-alhiiniin, which, injcct<Ml into uniriiulM,
pi-odn('(«s paralysis, nephritis, and alhurninnria. This point t4;ndH Htron^dy
to tMnHirni the view that tlii.s hacilhis is really tlio infcctivo a^frnt in tijo
disease. It is one of the most, virulent jjoiHoiiH known, and when in-
jeeted in a sutVieienlly .small thou«,di fatal <lose, there-may ho no Hvnip-
toniM for days, and (he animal may not develop the paralysin for weekn or
evtMi months al'lcr the iiijeetion. A point of very jjfrcat interest i.s the
faet tluit. cultures from ca.ses vary in viruh^nco, and this is in accord with
tho ronuirkahh^ variation in the intensity of different epidemics and difT«*r-
ont ca.se.s. A.s a rule there is a correspondence hetween the virulence of
tho bacilli and tlu» gravity of tlu^ ca.sc.
Associated with the Klebs-Loeffler bacillus are other pathof^enic bac-
teria, which i)robably play an im])ortant role in the complications of tho
disease. Thus streptococci and etiipliylococci arc frerjuently present in
the exudate, and to their invasion through the abraded mucosa are due
tho secondary suj^purations and inflammations of serous surface.^, and to
tho aspiration of tho streptococci into the lungs the common and fatal
broncho-pneumonia.
Diplitheria nuiy then bo said to be caused by the Klebs-Loeflfler bacil-
his. The production of a false membrane is the local or primary effect ;
the constitutional symptoms are due to the absorption of the poison in
varying doses, while the secondary inflammations are associated with the
invasion of tlie ubi(|uitous ])us organisms.
Pseudo-diphtheritic Processes. — Many substances have the power of
exciting pseudo-membranous or croupous inflammation, the exudate of
which is not distinguishable from that of diphtheria. Some of them are
non-microbic, as steam, ammonia, and chlorine ; others are dependent
upon micro-organisms, and must be distinguished from true diph-
theria.
(a) There are cases of pseudo-membranous angina, associated with
which is a bacillus identical, morphologically and in its behavior on cult-
ure media, with the Klebs-Loeflfler bacillus, but which is not pathogenic —
i. e., does not produce the tox-albumin, and is harmless when inoculated.
Whether this is an attenuated form, as Roux and Yersin hold, is not yet
settled. This complicates the question of diagnosis. A patient in my
ward presented a thin, grayish pseudo-membrane over the tonsils and
fauces, without fever and without constitutional disturbance. Xon-patho-
genic bacilli, identical with those of true diphtheria, were found by "Welch
102 SPECIFIC INFECTIOUS DISEASES.
and Abbott. We need additional information upon the occurrence of this
form and its relation to the virulent bacillus.
(b) The pseudo-membranous angina of the eruptive fevers is an affec-
tion distinct, etiologically at least, from true diphtheria. In a majority
of all these cases, particularly in scarlet fever, the Klebs-Loeffler bacillus
is absent, and this is in accord with the fact that scarlatinal angina rarely
communicates diphtheria, and is still more rarely followed by paralysis.
Streptococci and staphylococci are present in the membranes in these
cases. Late in the disease infection with the bacillus diphtherice may oc-
cur, and it is probable that under these circumstances alone is the angina
followed by symptoms of paralysis.
Morbid Anatomy. — A majority of the cases die of the faucial or
of the laryngeal disease. The exudation may occur in the mouth and
cover the inner surfaces of the cheeks ; it may even extend beyond the
lips on to the skin. This was met once in thirty autopsies at the Mont-
real General Hospital. The amount of exudation varies in different cases.
Usually the tonsils and the pillars of the fauces are swollen and covered
with the false membrane More commonly, in the fatal cases, the exuda-
tion is very extensive, involving the uvula, the soft palate, the posterior
nares, and the lateral and posterior walls of the pharynx. These parts are
covered with a dense pseudo-membrane, in places firmly adherent, in
others beginning to separate. In extreme cases the necrosis is advanced
and there is a gangrenous condition of the parts. The membrane is of a
dirty-greenish or gray color, and the tonsils and palate may be in a state
of necrotic sloughing. The erosion may be deep enough in the tonsils to
open the carotid artery, or a false aneurism may be produced in the deep
tissues of the neck. The nose may be completely blocked by the false
membrane, which may also extend into the conjunctivae and through the
Eustachian tubes into the middle ear. In cases of laryngeal diphtheria
the exudate in the pharynx may be extensive. In many cases, however, it
is slight upon the tonsils and fauces and abundant upon the epiglottis and
the larynx, which may be completely occluded by false membrane. In
severe cases the exudate extends into the trachea and to the bronchi of
the third or fourth dimension. This occurred in nearly half of my tliirty
Montreal autopsies.
In all these situations the membrane varies very much in consistency,
depending greatly upon the stage at which death has occurred. If death
has occurred early, it is firm and closely adherent ; if late, it is soft, shreddy,
and readily detached. When firmly adherent it is torn off with difficulty
and leaves an abraded mucosa. In the most extreme cases, in which there
is extensive necrosis, the parts look gangrenous. In fatal cases tlie lym-
phatic glands of tlie neck are enlarged and there is a general infiltration
of the tissues with serum ; the salivary glands, too, may be swollen. In
rare instances the membrane extends to the gullet and stomach.
Histological Changes. — We owe largely to the labors of Wagner, Wei-
* hii'ii'riii:i:i.\. 103
^(M'f, Mini riinii' pariiciiljuly lo tlio Hplnnliil work of Ocrtul, our kTiowIeil^tj
of till- iiiiiiiih- (Imii^oH wliicli \nko placr in (iiplitlicriii. 'l\w following in
a hricf aliMtnirl nf ilm vi«'\VH nf the last-imiiKMl author :
'riHMli|)lil licrilic pnisnii iiidiKM'M firHt a lU'cro.siH or dratli of cclU uitli
wliici) it coiiicM ill (oiitact, particularly tlio Hti))crfi('ial cpitlH-liiirii ami tho
Imitiooytc'M. TIm* drcpcr ccIIh of the iiiiicoHa and of tlin otlu-r partn n-arlio*!
by iho poinon may also Itr alTictrd. TIh' second chan^^o jh hyiiliiio trans-
roi-mat ioii of the dcid cells, or, as Wci^'crt tcrmn it, the prodiictirin of co-
aj^MJat inii-mu'rosis. 'The haeilli excite intlammation witli tin; mi^'ration of
Ituu'ocytcs, which ai'e destroyed hy tlie poison and nnder;,'o the hyaline
eluin«::e. The sMi)erlicial epithelial layers under^^^o a similar alteration, and
what we know as the false memhrane represents an a^'«^'re;^'ation of dead
cells, most of which have undeiL^^onc the transformation into hyaline ma-
terial. This is in all piohahility a conservative process by whicli, in a
measure, the j)oison is localized ami prevented from rea(;hing the deeper
structures. 'I'he laminated condition of tlie exudate is prol)a))ly j)roduced
by the inlhimmation of dilTerent layers. The formation of these f<K;i of
necrobiosis, start in«^ from the epithelium and })roceeding inward, i.s, ac-
cording to Oertel, the distinguishing cliaracteristic of diplitheria. The
action of tlie poison is by no means confined to the supertlcial mucosa
on which the bacilli grow. Althougli they do not themselves penetrate
dee})ly, the contiguous broncliial glands show extensive foci of necrosis.
In severe cases these necrotic areas are found in the internal organs, in the
solitary glands of the intestines, and in the mesenteric glands.
The blood-vessels may themselves be much altered and the capillaries
may show extensive hyaline degeneration. Every one of the histological
changes described by Oertel in human diphtheria may be paralleled in the
experimental disease induced by the Klebs-Loeffler bacillus, particularly
the necrotic areas in the deep-seated organs, associated in the lymph-glands
with a remarkable fragmentation of tlie nuclei.
The changes in the oflicr organs are variable. "When death has oc-
curred from asphyxia there is general congestion of the viscera.
Capillary bronchitis, areas of collapse, and patches of broncho-pneu-
monia are almost constantly found in fatal cases. In very malignant cases
the blood may be lluid. Fibrinous coagula may be found in the heart, but
the wide-spread idea that they may cause sudden death is erroneous,
^lyocardial changes are not infrequent, and in certain cases sudden death
is due to heart-failure in consequence of degeneration of the muscle-fibres.
Endocarditis is extremely rare. It was not present in one of my thirty
autopsies. The serous membranes often show ecchymoses. The kidneys
present parenchymatous changes, such as are associated with acute febrile
affections. There may, however, be acute nephritis. The spleen and liver
show the usual febrile changes. The spleen is, however, not always
enlarged.
Symptoms. — The period of incubation varies. In the cases of acci-
8
104: SPECIFIC INFECTIOUS DISEASES.
dental inoculation the duration is from two to three days. In cases in
which the disease is contracted in the usual way it is from seven to twelve
days. The initial symptoms are those of an ordinary febrile attack : slight
chilliness, fever, and aching pains in the back and limbs. In mild cases
these symptoms are trifling, and the child may not feel ill enough to go
to bed. Usually the temperature rises to 103° or even more. There may
be convulsions at the outset. In an attack of ordinary severity there is
at first redness of the fauces, and the child complains of slight difficulty
in swallowing. The exudate first appears upon the tonsils. It may be
difficult to distinguish the patchy diphtheritic pellicle from the exudate
in the tonsillar crypts. The swelling of the throat increases and the
glands of the neck become involved. Usually by the third day the mem-
brane has covered the tonsils, and crept on to the pillars of the fauces, and
even to the uvula, which is now thickened and oedematous and completely
fills the space between the swollen tonsils. The false membrane may ex-
tend also to the posterior wall of the pharynx. At first grayish white in
color, it changes to a dirty gray, often a yellowish gray. The membrane
is firmly adherent, and if removed leaves a bleeding, somewhat eroded
surface. New membrane rapidly forms in place of that removed. The
general condition of the patient, in a case of moderate severity, is fairly
good. The temperature is not necessarily high, and in the absence of
complications the range is from 102° to 103°.
At this stage, say the fourth or fifth day of the disease, the condition
of the child is favorable. The pulse and temperature are not much above
100° ; the throat symptoms are not of extreme severity ; and the constitu-
tional depression is not extreme. The symptoms may then abate and the
swelling of the neck diminish. The false membrane separates, and by the
eighth or tenth day the throat is clear and convalescence begins.
Deviations from this favorable course result either from extension of
the local disease or from systemic infection.
(1) Extension. — The inflammation may pass into the posterior nares,
obstructing the respiration, causing a very acrid and foetid discharge, and
usually a marked aggravation of the constitutional symptoms. The
glandular inflammation is usually more intense ; due, as Jacobi points
out, to the greater richness of the nasal mucosa in lymphatics, which thus
favors systemic infection. Though usually secondary, nasal diphtheria
may be primary. It greatly increases the danger in any case. From the
nose the inflammation may extend through the tear-ducts to the conjunc-
tivae and into the antra. In these cases the disease is more apt to
involve the ears, through the Eustachian tubes, causing otitis media and
perforation of the drum.
Extension of tlie inflammation downward into the larynx is by far
the most serious complication of the disease. It is particularly dangerous
in children, because it produces what is known as diphtheritic croup.
The symptoms are identical with those of ordinary membranous croup.
I'li'irnii'inA. 105
III tiiiiiiy iiiH(an(M<M tlir |tiiiiryiix in but Hti^litly involved. Tlicru fiiuy \m
only H trilliii;^' l>uli-li ii|inii niio ioiiNil. Tlitf flrHt HytiiptoniM of Ijiryii;:(-ul
iilTcctioii art' hiislviiicHM of tiir voice, u lini/m coiii^'li, uihI Htri<IuloiiM, iioJMy
iiispinitioM 1111(1 cxpinitioii. With iiicrraMin;; olmtriiction tint rcMpirution
liccomc's ^M'l'ally cmltanasscMl, tlir low<'r tliora<'i(t zone? uiid tlio lowrr nirr-
iiiiiii AW" drawn in with carh iiiMpiratioii, uiid the Hiiprii-cluviculur und
iiilcrcostul spaces jin^ dcprcHHcMl. Too often then? in u ^ruduiilly (loc!|>fi)in^
cyanosis, and tlic child dies asphyxiated.
Tlic exudation may extend into the trachea and ))ron(lii, ^v)u<•ll hecMnc
lined hv a uniform slu'etin<^ of fals(^ niemhrane. it is not always easv to
say, during life, whether exudation has taken j)la(;(f into these; parts. In
the pciformaiicc of tracheotomy, when nicmlirano is found in the trtudiea
the outhxtk is i^^cncrally l»a<l. Occasionally the tracheal and hronchiul
nuMnhrane is cou^du'd uj) as a delinito mould.
(v*) Systemic Infection. — In mild cases of diphtheria the constitutional
disturhanco is very slii^dit, There may even be extensive local disea.se
without great constitutional disturbance. As a rule, however, the general
symptoms bt>ar a dclinite ])roportion to the severity of the local disejtse.
There are rare instances in which from the outset, even before the pharyn-
geal symptoms are at all well-marked, the constitutional prostration is
extreme, the pulse fre(|uent and small, the fever high, the nervous plie-
nomena are pronounced ; and the patient sinks in two or three days, over-
-whelmed by the severity of the poison. In some of these cases the exuda-
tion is chielly nasal ; in others the exudation is marked, but tlie throat
symptoms are by no means extensive. It is specially to be noted that the
temperature may not bo raised ; it may even be subnormal. The malig-
nant diphtheria of this kind is fortunately rare. The severe systemic
symptoms appear more commonly at a later date, when the j)haryngeal
symptoms are at their height. They are invariably met when the disease
is extensive and when there is a sloughing foetid condition in the pharynx
causing an offensive odor of the breath. The lymphatic glands are greatly
enlarged ; the pallor is extreme, the color of the face an ashen gray, the
pulse is rapid and feeble, and the temperature sinks below normal. In
the most aggravated form there are gangrenous processes in the throat.
If life is prolonged there may even be extensive sloughing in the tissues of
the neck.
There are, of course, many variations in the above clinical picture.
The cases may be so mild as scarcely to be recognized. Such cases, in-
deed, are often mistaken for ordinary lacunar tonsillitis. There are also
certain anomalous forms which may be mentioned ; cases which come on
insidiously, with a tonsillitis of so mild a grade that it may be overlooked,
and which is followed by a diphtheritic croup or a severe broncho-pneu-
monia. In rare instances the disease may almost be termed chronic, since
the membrane remains upon the tonsils and pharynx for weeks.
106 SPECIFIC INFECTIOUS DISEASES.
There are instances in which well-characterized pseudo-membrane
occurs on the tonsils and fauces without much swelling and without
severe constitutional disturbance. A young woman came to my clinic at
the University Hospital, Philadelphia, whose tonsils, soft i)alate and
uvula were covered with a smooth, firm, grayish-white pseudo-membrane.
There was little or no swelling of the parts, the membrane was clean, its
edges were well defined, and on removal of the membrane the mucosa
beneath bled freely. The exudation had all the characters of false mem-
brane. The patient had scarcely any constitutional disturbance. The
temperature was below 100°, and she had not felt ill enough to go to bed.
After persisting for eight or nine days the membrane was gradually re-
moved, and she recovered without any ill effects. The membrane may
appear first upon the mucous membrane of the mouth, or it may attack
the conjunctiva or the external auditory meatus. Occasionally the vulva,
prepuce, or anus is first attacked. In rare cases the skin is involved.
AVhen the disease is epidemic, external wounds and abrasions are apt to
be infected. In recently delivered women the disease may attack the
uterus or vulva.
Complications and Sequelae. — Local complications, hasmorrhage
from the nose or throat, may occur in the severe ulcerative cases. Skin
rashes are not infrequent, particularly the diffuse erythema. Occasion-
ally there is urticaria and in the severe cases purpura. The pulmonary
complications are extremely important. Fatal cases almost invariably
show capillary bronchitis with broncho-pneumonia and large patches of
collapse. In very bad cases, with extensive sloughing, the septic particles
may reach the bronchi and excite gangrenous processes which may lead
to severe and fatal haemorrhage.
Renal complications are common. In my experience albuminuria is
present in all severe cases. It may cause with the usual tests only a slight
turbidity of the urine, the ordinary febrile albuminuria. In others there
is a large amount of albumen, curdy in character. It is only when the
albumen is in considerable quantity and associated with epithelial or
blood casts that the condition indicates parenchymatous nephritis and is
alarming. The nephritis may be quite early in the disease. It sets in
occasionally with complete suppression of the urine. In comparison with
scarlet fever the renal changes lead less frequently to general dropsy. In
the large number of cases of diphtheria which came under observation at
the Montreal General Hospital, I call to mind only one or two instances
in wliich the ne2)hritis was associated with general anasarca. Arthritis is
an occasional complication just as in scarlet fever. Endocarditis, peri-
carditis and pleurisy are very rare events.
Of the sequela} of diphtheria, paralysis is by far the most important.
This can be experimentally produced in animals, as already noted, by the
inoculation of the toxic albumen produced by the bacilli. The paralysis
occurs in a variable proportion of the cases, ranging from 10 to 15 and
hllMI rilKKIA. 107
(U'cM lo 'vO jMT cent. It JM Hiricllv it Hr«|iirl nf the (li^«'i-.- 'Mrniri^ on u>^u-
ully in tlu' Hccoud (»r lliird week at coiivulrMmicr. <' iwilly it rorin-H
jiH fiirly nn {\\v scvnitli or ci;^'!!!!! <l;iy <>f th(5 diHcji-^**. It nmy follow wry
mild niHOH; indeed, tin* IochI (lim'HHo. nuty bo ho trilling tlmt tlio oiim't of
the piiralysiH idone <ii1Ih iittention to thn trno nuturu of thu trouble
The diseases is u toxic nenriiis, due to i\w >i))Hor|»tion of tbo jM.i-'»n,
and, like other forms of multiple neuritis, has an extremely complex
symptomatolo;^'y, aeconlin;^ to tlio norvt'H which are alTected. 'J'he ]uiraly-
sis nuiy he Incai oi- ;^^'lieial.
of tile local paralyses tlu^ most common h that which affectH the
palate. This ^ives a nasal (duiraeter to thu voice, and, owin^ to u return
of liijuids throuL,di th(» nose, causes a diHiculty in swallowing'. This may
1)1' the only symptom. Tlu' velum is sei'n to he relaxecl and niotioideH/<,
and the sensation in it is also much impaired. The alTection may extend
to the constrictors of the pharynx, aiul deglutition become embarrasse<l.
AVithin two or three weeks or even a shorter time the paralysis disa])pears.
In numy cases the alTection of the palate is only part of a general neuritis.
Of other local forms perha})s the most common are paralysis of the eye-
muscles, intrinsic and extrinsic. There may Ijc strabismus, ptosis, and
loss of power of accommodation. The neuritis may be confined to the
nerves of one limb, thougli more commonly the legs or the arms are af-
fected together. Very often with the palatal ])aralysi3 is associated a
weakness of the legs Avithout definite palsy but with loss of the knee-jerk.
By far the most ini})ortant local paralysis is met with in connection
with the heart. There may be great retardation, even to thirty beats in the
minute. Bradycardia and tachycardia may alternate in the same patient.
Heart-failure and fatal syncope may occur at the height of the disease or
during convalescence. If they occur during the fever, the child, perhaps
after an exaggeration of symptoms, presents an unusual pallor. The
pulse becomes weak and ra})id, but may fall to fifty, forty, or even lower.
The extremities are cold, the temperature sinks, and death takes place,
with all the features of collapse, within a few hours. More frequently the
fatal collapse comes during convalescence, even as late as the sixth or
seventh week after apparent recovery. The attack may set in abruptly,
perhaps following a sudden exertion. More commonly there have been
symptoms pointing to disturbed cardiac rhythm, or even fainting-spells. In
some instances vomiting has preceded the serious cardiac attack. There
may be no physical signs other than slight increase in the cardiac dulness
and a gallop-rhythm indicating dilatation. These symptoms were formerly
ascribed to cardiac thrombosis or to endocarditis. Possibly in some of
the cases the result is due, as pointed out by Mosler and Leyden, to an in-
fectious myocarditis, but in a majority of the cases the symptoms are
probably due to a neuritis of the cardiac nerves.
The multiple form of diphtheritic neuritis is not uncommon. It may
begin with the palatal affection, or with loss of power of accommodation
108 SPECIFIC INFECTIOUS DISEASES.
and loss of the tendon reflexes. This last is an important sign, which, as
Buzzard and R. L. MacDonnell have shown, may occur early, but is not
necessarily followed by other symptoms of neuritis. There is paraplegia,
which may be complete or involve only the extensors of the feet. The
disease may extend and involve the arms and face and render the patient
entirely helpless. The muscles of respiration may be spared. The chief
dansrer in these severer forms comes from the involvement of the heart
and of the muscles of respiration ; but the outlook is in many cases not
so bad as the patient's condition would indicate. Of thirteen cases col-
lected by Cadet de Gassicourt six died. The sphincters may be involved,
though they are often spared.
Diagnosis. — Early in the disease it may be difficult to distinguish
diphtheria from follicular tonsillitis. In mild cases it is sometimes impos-
sible. In diphtheria the exudation forms a definite, uniform patch, situ-
ated on a deeply congested area of mucosa. In follicular tonsillitis, when
the exudate oozes and if the material from the crypts coalesces, it may be
extremely difficult to make a diagnosis. If the process is confined to the
tonsils the nature of the case may be dubious. If, however, it extends to
the pillars of the fauces and if laryngeal symptoms develop, all doubts are
removed. Occasionally the true character of the disease is not manifested
until a paralysis develops during convalescence. It is in these cases that
the detection of the Klebs-Loeffler bacillus will be of the greatest service
in making clear the diagnosis. Cover-glass preparations may be made
from the membrane. Cultures should be made in the blood-serum and
bouillon mixture, and inoculations performed on animals. Unfortunately,
these procedures can scarcely be carried out except in well-equipped labora-
tories, and a ready and certain clinical method, such as we have for the
tubercle bacillus, is not yet available.
Between diphtheritic laryngitis and croup a majority of writers now
hold that there is no essential difference ; but it is more rational to believe
that there is a non-specific pseudo-membranous laryngitis. This is a
point, too, which bacteriology may be able to clear up. In several cases
which have been examined the Loeffler bacillus has been present. The
diagnosis between the two conditions is by no means easy. In the diph-
theritic form, however, there is almost invariably exudation upon the ton-
sils or soft palate. Between scarlet fever and diphtheria there may be
some confusion The question has already been discussed.
The recognition of the diphtheritic paralysis offers no difficulties.
Prognosis. — In hospital practice the disease is very fatal, owing
largely to the fact that only the severer forms are admitted. In country
places epidemics may display an appalling virulence and kill nearly all
the children attacked. In cases of ordinary severity the outlook is usually
good. Death results from involvement of the larynx, septic infection,
sudden heart-failure, di})hthcritic paralysis, occasionally from ura?mia, and
sometimes from broncho-pneumonia developing in the convalescence.
hiniTIIKUIA. 109
Troatmont. rropliyluxiH. ('umch of (li|.litlii'riii mIiouIiI invariuhly
be isniuhd, I'liy.siciiiiis sIkhiM iii.siML llijit otluT rljildrm in iIm? fiiriiil)' Ikj
kept rrnin school uiiii rioin iiiiii^^liiii^ with th(*ir HrhoolfriutfM. All doih-
in;(iiiiil iilrtisils w liirh hii\r Im m iihimI hy th(^ ))iiti()iit Hhotild hu thoroii^lily
(lisinrcrird. I'm- this |nirpo.so thr clothing iiiiiy Im? Houkrd for twenty-four
hoiiis ami tlicii hoilcd iiui two-pcr-ccnt cailxdic H(diitioii. Kor diriinfrctiii^
tiu' rooiM sulphitr riniii^^Mitioii may )m> cinploycd, taking' caro that the air Im
rt'iidcied iimist, or the llnor and walls hhoidd \h' thoroii^ddy H<,-oiired with
corrosivo-suhliinato Holutioii.
Caillo has urmd the impoilaiicc of a canTiil inspection of the tonflilfl
and mouth in diildnii, special attention ))ein^ j)aid to the care of the
teeth and (o the tonsils, wiiich, if Hwollen and irre^Mdar, slionld he re-
moved. In persons liald(^ to exposure liOcHlcr recommends the use of
antiseptic? mouth- washes, such as Hublinuite (I to 1(),()()0), chlorine- water
(1 to 1,100), or thymol. After recovery at least two weeks should elapse
before the child is permitted to min«,do with otliers or to return to school.
Ivecently it has been announced tlnit the blood-serum of animals ren-
dered secure a<j^ainst the diphtheritic bacillus and its products can nullify
the elTects of the ])ois()n of diphtheria.
General Treatment. — The two indications in the treatment of diphthe-
ria are to prevent or limit the local development of the bacilli and to com-
bat the olTects of the toxic materials which they produce.
The usual measures sliould be employed to insure thorough cleanli-
ness and ventilation and to diminish the danger of infection. The air
should be kept moist with steam. Mild cases require but little treatment.
A fair quantity daily of licpud food, with ice to suck, and a gargle of chlo-
rate of potash are sut!icient. In more severe cases the greatest care should
be taken to maintain the strengtli of the patient. The food should be
given at stated intervals. Stimulants will be required early and should be
given freely. In very young children witli the pharyngeal involvement
swallowing is painful, and the giving of food by the mother or nurse is a
continuous struggle. In such instances nutritive enemata should be used.
We are still without a remedy capable of combating in any way the
effects of the poisonous tox-albumins. Two remedies are warmly recom-
mended— the tincture of the perchloride of iron, which may be given hourly
in four or live drop doses to a child of three, and the corrosive sublimate,
of which a child a year old may take as much as half a grain a day. Per-
sonally, I much prefer the perchloride of iron ; and I cannot say that I
have seen from the mercury, given either as the bichloride or as calomel,
the specially good effects which many writers describe. I have not seen
any good follow the administration of the sulphides or the benzoates or
quinine in large doses. Peroxide of hydrogen has been warmly recom-
mended.
Local Treatment. — Diphtheria is a local disease at first, and by the
production of poisonous substances causes the severe systemic symptoms.
110 SPECIFIC, INFECTIOUS DISEASES.
Hence the importance of local treatment. It is not well to attempt forcibly
to remove the false membranes, though some writers recommend that they
should be scraped off. As far as possible thorough cleanliness and disin-
fection of the fauces should be insured by repeatedly spraying, either with
carbolic acid, corrosive sublimate (two grains to the pint), chlorine- water,
boric acid, Condy's fluid, salicylic acid or peroxide of hydrogen (50 per
cent solution), or local application of sulphur with iodoform is recom-
mended. The tonsils and fauces may be thoroughly swabbed every hour
or two with a solution of carbolic acid (tt[xv) and perchloride of iron
( 3 ijss.) in glycerin ( ? j) and water ( § j). Agents which are believed to
dissolve the membrane are lactic acid, which may be employed with lime-
water (two drachms to six ounces) and trypsin (thirty grains to the
ounce).
Pepsin has also been used, and the vegetable pepsin, which may be
mixed with water and glycerin.
Nasal diphtheria requires prompt and thorough disinfection of the
passages. The best solutions are those recommended by Jacobi — chloride
of sodium, saturated boric acid, or one part of bichloride of mercury,
thirty-five of chloride of sodium, and one thousand of water, or the one per
cent solution of carbolic acid. The solution may be applied with a syr-
inge or a spray. To be effectual the injection must be properly given.
The nurse should be instructed to pass the nozzle of the syringe horizon-
tally, not vertically ; otherwise the fluid will return through the same nos-
tril. In refractory children there is sometimes great difficulty in giving
these injections, in which case suppositories of boric acid may be em-
ployed, but they are not efficient substitutes.
When the larynx becomes involved a steam tent may be arranged upon
the bed, so that the child may breathe an atmosphere saturated with moist-
ure. If the dyspnoea becomes urgent, an emetic of sulphide of zinc or
ipecacuanha may be given. When the signs of obstruction are marked,
however, there should be no delay in the performance of intubation or
tracheotomy. The diphtheritic paralysis requires rest in bed, and the avoid-
ance of sudden exertion, particularly in those cases in which the heart-
rhythm is disturbed. In the chronic forms with wasting, massage, elec-
tricity and strychnine are invaluable aids. If swallowing becomes very
difficult, the patient must be fed with the stomach-tube, which is very
much preferable to feeding per rectum.
XVI. ERYSIPELAS.
Definition. — An acute, contagious disease, characterized by a special
inflarniMiitioii of the skin caused by streptococci.
Etiology. — Erysipelas is a wide-spread affection, endemic in most
communities, and at certain seasons epidemic. We are as yet ignorant of
KIlYSIlMOIiAS. 1 11
l\\o iilnioMpliiM'ic or Irllnric inlIiiiiiccM wliidi fuMtr tlio ilifTuMioii of the
poison.
II is |tarlii'iilHi'Iy prcvulciil in llio Hpriii|^' of tlir yviiv. 'lliiA wiw vcrv
iioli((-!il)l(< in till' IMiiliidclpliia IIns|)iial, in which i\\v oryHJjH'hui wurdit
\V('i'(^ iisiiully (iiipty rxcopt in ihn spring iiiid iiiitiiinii iitonthH. Thu ufTec-
lion prevails cxttwiHivdy in (»l(i ill-vcntihitcd liospitals aiiii ini^titnlionri in
which l\\v sanitary coiulitions arc defective. \\ illi tlic improved nanitu-
lion of hil(» years the nninher of cases has materially diminihhed. It hiw
hccn ol)si'rvcd, however, to i)reak ont in n(!W iiiHtitutioiiH under tho moHt
favoral)le hy^it'nic ciicnnistanceH. KryHipehiH i.s hoth conta^nouH and in-
ocnlal)h> ; luit, excopt under special conditions, the j)oiHoii irt not very
virnl(>nt and does not sei'in to act at any <^n*eat distance. It can he con-
veyed l)y a third person. The poison certainly attaches itself to tin; fur-
niture, heddiui^, and walls of rooms in which patients have heen confined.
'riu> disposition to the disease is wide spread, hut the susceptihility id
specially nuirkcd in the case of individuals with wounds or ahra.sions of
any sort, liecently delivered women and persons who have heen tlie sub-
ject of suri^ical operations are }>artii'ularly prone to it. A wound, hr)W-
ever, is not necessary, and in the so-called idiopathic; form, althougli it
may bo dillicult to say that there was not a slight abrasion about the nose
or lips, in very many cases there certainly is no observable external lesion.
Chronic alcoholism, debility, and Jiright's disease are predisposing
agents. Certain persons sliow a special susceptibility to the disease, ami
it may recur in them repeatedly. There are instances, too, of a family
predisposition to the disease.
The specilic agent of the disease appears to be a streptococcus which
has been very thoroughly studied by Koch and Fehleisen. It was believed
at first to have specific and peculiar morphological properties, but it is now
generally held that it cannot be distinguished by any biological or chem-
ical tests from the sfrfpforoccus pijogows.
Morbid Anatomy. — Erysipelas is a simple inflammation. In its
uncomplicated forms there is seen, post mortem, little else than inflamma-
torv aniema. Investicjations have shown that the cocci are found chiefly
in the lymph-spaces and most abundantly in the zone of spreading inflam-
mation. In the uninvolved tissue beyond the inflamed margin the mi-
crococci are to be found in the lymph-vessels, and it is here, according to
MetsehnikotT and others, that an active warfare goes on between the leuco-
cytes and the cocci (phagocytosis). In more extensive and virulent forms
of the disease there is usually suppuration. It is stated that the inflam-
mation may pass inward from the scalp through the skull to the meninges.
This I have never seen, but in one case I traced the extension from the
face along the fifth nerve to the meninges, where an acute meningitis and
thrombosis of the lateral sinus were excited.
The visceral complications of erysipelas are numerous and important.
The majority of them are of a septic nature. Infarcts occur in the lungs,
112 SPECIFIC INFECTIOUS DISEASES.
spleen, and kidneys, and there may be the general evidences of pyaemic
infection.
Some of the worst cases of malignant endocarditis are secondary to
erysipelas ; thus of twenty-three cases three occurred in connection with
this disease. Septic pericarditis and pleuritis also occur.
As just mentioned, the disease may in rare cases extend and involve
the meninges. Pneumonia is not a very common complication.
Acute nephritis is also met with. It is often ingrafted upon an old
chronic trouble.
Symptoms. — The following description applies specially to erysipelas
of the face and head, the form of the disease which the physician is most
commonly called upon to treat.
The incubation is variable, probably from three to seven days.
The stage of invasion is often marked by a rigor, and followed by a
rapid rise in the temperature and all the characters of an acute fever.
When there is a local abrasion, the spot is slightly reddened ; but if it is
idiopathic, there is seen within a few hours slight redness over the bridge
of the nose and on the cheeks. The swelling and tension of the skin
increase and within twenty-four hours the external symptoms are well
marked. The skin is smooth, tense, and oedematous. It looks red, feels
hot, and the superficial layers of the epidermis may be lifted as small
blebs. The patient complains of an unpleasant feeling of tension in the
skin ; the swelling rapidly increases ; and during the second day the eyes
are usually closed. The first-affected parts gradually become pale and
less swollen as the disease extends at the periphery. When it reaches the
forehead it progresses as an advancing ridge, perfectly well defined and
raised ; and often, on palpation, hardened extensions can be felt beneath
the skin which is not yet reddened. Even in a case of moderate severity,
the face is enormously swollen, the eyes are closed, the lids greatly
oedematous, the ears thickened, the scalp is swollen, and the patient's
features are quite unrecognizable. The formation of blebs is common on
the eyelids, ears, and forehead. The cervical lymph-glands are swollen,
but are usually masked in the oedema of the neck. The temperature keeps
high without marked remissions for four or five days and then deferves-
cence takes place by crisis. The general condition of the patient varies
much with his previous condition of health. In old and debilitated per-
sons, particularly in those addicted to alcohol, the constitutional depression
from the outset may be very great. Delirium is present, the tongue be-
comes dry, the pulse feeble, and there is marked tendency to death from
toxaemia. In the majority of cases, however, even with extensive disease,
the constitutional disturbance, considering the height of the fever range,
is slight. The mucous membrane of the mouth and throat may be swollen
and reddened. 'J'lie erysipelatous inflammation may extend to the larynx,
but the severe (rdema of tliis part occasionally met with is commonly
due to extension of the inflammation from without inward.
KUVSIPKLAS. 113
Tlu^ro iiro (*]iH(*H ill wliirli tin* iiinnfinniitiMn cxtcMilH from tho tiwaio thu
iMM'k, iiiul <»vrr tli(< clu'Mt, jind may /^Mii<liiiilly iMi;;niU) or wiiinlrr ov<?r tlio
^Ti'iilcr |Mirt of llic Ixxly (A', inn/r/in.s).
Thu closer relation hetwiM'ii thu (TyHipchin focciiM iunl i\u) |mim orj^anlMnifl
in sliowii l»y ihc fr('(|ii('iicy with which Hiipjiunition ov.nirH in fiu'iul rry-
si{i(>his. Small ciitaiUMXiM uhricu^MscH iiru coiiimioh ahotit tho chockN uiwl
forehead ami iieek, and l)oneHth tlio Hculp lar^'e colh-ctioiiH of pun may uc-
eiinmlatc. Siippiiralioii Keerim to oc(!iir more frefjiienlly in Home epidernies
than in oth(>rs, and at. the lMiihi(h*Iphia lIosj>ital one year nearly uil thu
eases in tlie erysipelas wards prenented h)eal ul)HeeH80S.
Complications. .MeMin<^iti.s is rare. Tho cosch in whirli death
occurs with uiaikcd hrain sym[>tomH do not UHUully nhow, j)f)Ht mortem,
menini^eal alTcction. The (Icliiiuin and coma arc; due to tlifj fever, or to
toxa'inia.
IMieunionia is an occasional complication. I'lctsrative endocarditis
and septieaMuia are more common. Alhuminnria is almost con.stant,
})artieularly in i)crsons over llfty. True nephritis is occasionally seen.
Pa Costa has called atti'ution to curious irregular returns of tlio fever
which occur duiing convalescence without any aggravation of the local
condition.
The diagnosis rarely i)rcsents any ditliculty. 'J'lie moile of onset, tlie
rapid rise in fever, and the characters of the local disease are qnite dis-
tinctive. Acute necrosis of bone may sometimes be regarded as erysipelas,
a mistake which I once saw made in connection with the lower end of the
femur.
Prognosis. — TIealtliy adults rarely die. In the new-born, when th.^
disease attacks the navel, it is almost always fatal. This is probably an
acute septic infection. In alcoholic subjects and in the aged erysipelas is
a serious affection, and death may result either from the intensity of the
fever or, more commonly, from toxa3mia. The wandering or ambulatory
erysipelas, which has a more protracted course, may cause death from
exhaustion.
Treatment. — Isolation should be strictly carried out, particularly in
hospitals. A i)ractitioner in attendance upon a case of erysipelas should
not attend cases of confinement.
The disease is self-limited and a large majority of the cases get well
without any internal medication. I can speak definitely on this point,
having, at the Philadelphia Hospital, treated many cases in this way. The
diet should be nutritious and light. Stimulants are not required except
in the old and feeble. For the restlessness, delirium, and insomnia, chloral
or the bromides may be given ; or, if these fail, opium. When fever is
high the patient may be bathed or sponged, or, in private practice, if there
is an objection to this, antipyrin or antifebriu may be given.
Of internal remedies believed to influence the disease, the tincture of
the perchloride of iron has been highly recommended. At the Montreal
llj- SPECIFIC INFECTIOUS DISEASES.
General Hospital this was the routine treatment, and doses of half a
drachm to a drachm were given every three or four hours. I am by no
means convinced that it has any special action ; nor, so far as I know, has
any medicine, given internally, a definite control over the course of the
disease.
Of local treatment, the injection of antiseptic solutions at the margin
of the spreading areas has been much practised. Two per cent solutions
of carbolic acid, the corrosive sublimate and the biniodide of mercury
have been much used. The injection should be made not into but just
a little beyond the border of the inflamed patch. F. P. Henry has treated
a large number of cases at the Philadelphia Hospital with the latter drug,
and this mode of practice is certainly most rational.
Of local applications, ichtliyol is at present much used. The inflamed
region may be covered with salicylate of starch. Perhaps as good an appli-
cation as any is cold water, which was highly recommended by Hippocrates.
XVII. SEPTICi^MIA AND PYvCMIA.
1. SEPTICEMIA.
Definition. — A general febrile infection, without foci of suppura-
tion, which results from the absorption of toxic materials produced by
bacteria. The organisms producing septicaemia are, as a rule, those of
suppuration — namely, the forms of streptococci and staphylococci.
Clinical Forms.* — (a) Fermentation Fever. — This is also known as the
resorption fever, aseptic fever, or after fever, and is the simplest of all wound
complications. It is the febrile process which is produced after transfusion
or the injection of pepsin into the blood. The term fermentation fever
was employed by Bergman, as he held that it was caused by the absorption
of the fibrin ferments. This fever may follow an injury or operation, par-
ticularly if there has been necrosis of the superficial tissues by the solu-
tions used in the dressing. It may also follow the extravasation of blood,
particularly when under pressure or tension.
The fever, which appears a few hours after the injury or operation, is
not preceded by a chill. It usually reaches its height rapidly, sometimes
rising to 103° or 104°. The constitutional disturbance is not great, and
it subsides spontaneously in from one to three days. This form is ranked
as a septica3mia, since the ferment acts in a manner similar to the toxins
produced by micro-organisms. It is not yet certain that bacteria do not
play an important part in its production.
(b) Saprmnia. — Tliis is a septic intoxication caused by the ptomaines
produced in wounds by the putrefactive bacteria. There are various forms
of these organisms ; some are bacilli, others belong to the proteus group.
* I follow here the division in Senn's Principles of Surgery.
BKITKMIMIA AND r^ .l.Ml A. I I T,
III tlitir ;j:r()u I li, cliniiicul poiHniiH (toxiiiH) iiro pnxliirrci], und undi'r iho
trnii sii|ir:i'iMiii in iiiclinN •! iIk^ ^(roiip of Hyin{it<>tiiM cuiimcmI by tliu ubriorp-
tioii of ilic.sn toxins fi'diii nuy local fociiH of jnitn-fiiclinri.
Tlici syiii|»toiiiH vary with \\w (1oh«< iil)Horl>r<l. 'rwrMty.fotir lioiirn, or
lutci', uriri- tli(* injury or opcnition a cliill iMitiutcH tlu; (-oiiHlitutional rlin.
tiirl)aii((' ; (lie* fcvi-r rises ra|»i«lly, n-achin;^' lo.T' or 104^; tlw jmiImo in (niick,
and tin IT niav, in scviio caHcM, l)o ^ri'ut proHtration. XcrvotiH Hymptoiiig
air ('onininM licadaclir, ri'.stlnHHnoHH, and drlirinni. 'The tofi^no in dry,
often ^la/cd, and ilnir may at lirHt bo gaHtric irritation. T\n) cliniral
pictnrc is llial (d' a severe infection. MMiree conditions irmst bi? |»n'Hcnt in
tins form of sepsis — dead tissno, infection of this dead tissue witli putre-
factive bacteria, and a sullicient time to liave enal)led the putrefactivt*
bacteria to produce a toxic (pumtity of ptomaines (Senn). The necrotic
tissue may b(> tlic l)l«)(id-cloi in a wound, the tisHues in tlie interior of tlie
uterus after part mil ion, or tissues bruised and rendered necrotic by injury
or by tlie action of cold, iieat, or clienucal substances.
'JMie outh)ok in sapruMuia (h'peiuls mucli upon the dose of the poison
wliich has been absorbed and tlie })ossibility of removin*,' and cleansing
the infected focus.
((•) Prut/rcssirc Svpticwmia. — In this the septic intoxication is not the
result of tlie bacteria of })ut refaction, but organisms enter the blood from
some local septic focus. *' The intoxication in this form of sepsis is not
only caused by })t()maiiies which are })roduced at the j)rimary seat of in-
fection, but ])tomaines are also produced in the blood by the microbes
which it contains " (Senn). The i)us microbes are the most frequent
cause of this form of septiciTmia, and reach the blood either through the
wall of the blood-vessels or through the lym]di-channels.
The clinical features of this form are well seen in the cases of puerpe-
ral septicaMuia or in dissection wounds, in which the course of the infec-
tion may be traced along the lym})hatics. The symptoms usually set in
within twenty-four hours, and rarely later than the third or fourth day.
There is a chill or chilliness, with moderate fever at first, which gradually
rises and is marked by daily remissions and even intermissions. The pulse
is small and compressible, and may reach 120 or higher. Gastro-intesti-
nal disturbances are common, the tongue is red at the margin, and the
dorsum is dry and dark. There may be early delirium or marked mental
prostration and apathy. As the disease progresses there may be pallor of
the face or a yellowish tint. Capillary haemorrhages are not uncommon.
The outlook is alwa3's serious. In severe cases death may occur within
twenty-four hours, and in fatal cases life is rarely prolonged for more than
seven or eight days. On post-mortem examination there may be no focal
lesions in the viscera, and the seat of infection may present only slight
changes. The spleen is enlarged and soft, the blood may be extremely
dark in color, and hemorrhages are common, particularly on the serous
surfaces. Neither thrombi nor emboli are found.
116 SPECIFIC INFECTIOUS DISEASES.
2. PYEMIA.
Definition. — A general disease, characterized by recurring chills and
intermittent fever and tlie formation of abscesses in various parts, all of
which result from the contamination of the blood by products arising
from a focus contaminated by the bacteria of suppuration.
Etiology. — As a rule, the disease follows extension of suppuration
about a wound or the collection of pus in some part. It was thought at
first that the pus itself was taken up by the blood. Yirchow showed the
important part played by thrombosis and embolism. The works of Lis-
ter, Klebs, Pasteur, Koch, and others have demonstrated the important
role of micro-organisms in the disease. The pus microbes are the strepto-
coccus pyogenes and forms of staphylococci. The streptococcus is most
frequently found in the pus at the primary seat and in the metastatic
abscesses.
The process which takes place is as follows : In a suppurating wound,
for example, the pus organisms induce coagulation-necrosis in the smaller
vessels with the production of thrombi and purulent phlebitis. The en-
trance of pus organisms in small numbers into the blood does not neces-
sarily produce pygemia. Commonly the transmission to various parts
from the local focus takes place by the fragments of thrombi which pass
as emboli to different parts, where if the conditions are favorable the pus
organisms excite suppuration. A thrombus which is not septic or con-
taminated, when dislodged and impacted in a distant vessel, produces only
a simple infarction ; but, coming from an infected source and containing
pus microbes, an independent centre of infection is established wherever
the embolus may lodge. These independent suppurative centres in pyae-
mia, known as embolic or metastatic abscesses^ have the following distri-
bution :
(a) In external wounds, in osteo-myelitis, and in acute phlegmon of
the skin, the embolic particles very frequently excite suppuration in the
lungs, producing the well-known wedge-shaped pyaemic infarcts ; but in
some cases the infected particles pass through the lungs, and there are foci
of inflammation in the heart and kidneys.
{b) Suppurative foci in the territory of the portal system, particularly
in the intestines, produce jnetastatic abscesses in the liver with or without
suppurative pyle-phlebitis*
(c) An interesting form of medical pyaemia is produced by malignant
endocarditis — the arterial pyaemia of Wilks — in which, as a result of in-
flammation of the endocardium (either secondary to suppurative disease
elsewliere, or following tlie infection of pneumonia or of certain general
diseases), showers of infected thrombi are conveyed from the vegetations
in the left heart and produce multiple abscesses in the spleen, kidneys,
intestines, brain, and even in the skin.
{(1) Til ere are cases of so-called idiojmthic pycemia in which the pri-
SKITK M:MIA ANI> rV. K.MIA. 117
iDiiry fociiM i»r I lie (liHciiHO in imt aiipamitf but in wliidi tlicru uro inulti|)lr
ii))S('(»HMrH in vari(»UH partH of tin* ImmIv.
Syni])toni8. In a ninv «»f woiiml infrrtioii, prior to iIm- ouMirt of tlio
(•luuu< In I I ir ,s\ mphuMM, tlicrr may Im« ni^MiH of loral trouhli-, uiwl, if n
(lis(liar;j:iii;^' uoiiihI, tlu- pus may rlian^i^ in rharactcr. 'I'lio onnc'l of tin?
(liHi'iisc is maiktil l>y a hc^vito rip)r, during which thi; temiMTutiin* rmm to
lOIJ' nr loi imd is foHowcil hy a profii.m^ HWcat. 'I'lifw? (;hiIlM urc n'fM'uttMl
al intervals, ('it her daily or nvory other day. In tin; iiitorvalH thrnj may
he sH^^dit pyrexia. The constitutional <listurhance in nuirke<l and then;
are htss of app(»lite, nausea, and vomiting', and, iis tlnr diseaM<' jiroj^rcHWH,
rapid loss of llesh. 'I'lansicnt erythenui is not uncommon. Local Hymj»-
tonis usually develop, if ihi' lun|^'H heeomo involved tiierc are dyspntea
and coiiL,di. The physical si«;ns nuiy be uli^^dit. Involvement of th('])leuni
an«l pericardium is coninioii. The tint of the skin is ciian^ed ; at first
pali^ and white, it sul)se(juently becomes bilct-tin^ed. 'I'he spleen in en-
lari^ed, and tliere may be intense ])ain in the side, point in;^' to ])erispleniti3
from end)olism. I'sually in the ra})id cases a ty])hoid state is ^^radually
develo]>ed, and tiie j)atient dies comatose.
In tlie clironic cases the disease may lie prolonged for months; the
cliills recur at long intervals, the temj)erature is irregular, and the condi-
tion of the })atient varies from month to montli. The course is usually
slow and progressively downward.
Diagnosis. — Pyivmia is a disease frecpiently overlooked and often
mistaken for other alTections.
Cases following a wound, an operation, or parturition are readily rec-
ognized. On the other hand, the following conditions may be over-
looked :
Osteo-myelitis. — Here the lesion may be limited, the constitutional
symptoms severe, and the course of the disease very ra})id. I recall two
instances in which the actual cause of the trouble was discovered only at
the post-mortem.
So, too, acute septic infection may follow gonorrhcea or a jyrostatic
abscess.
Cases are sometimes confounded with fi/phoid fever^ particularly the
more chronic instances, in which there are diarrhoea, great prostration,
delirium, and irregular fever. The spleen, too, may be enlarged.
In some of the instances of ulceratire endocarditis the diagnosis is
very difficult, particularly in what is known as the typhoid type of this
disease, in contradistinction to the septic. In acute miliary tuberculosis
the symptoms occasionally resemble those of septica?mia, more commonly
those of typhoid fever.
The post-febrile arthritides^ such as occur after scarlet fever and gon-
orrhoea, are really instances of mild septic infection. The joints may
sometimes proceed to suppuration and pya?mia develop. So, also, in tuber-
culosis of the kidneys and calculous pyelitis recurring rigors and sweats
118 SPECIFIC INFECTIOUS DISEASES.
due to sej^tic infection are common In this latitude septic and pyaemic
processes are too often confounded with malaria. In early tuberculosis,
or even when signs of excavation are present in the lungs, and in cases of
suppuration in various parts, particularly empyema and abscess of the
liver, the diagnosis of malaria is made. The practitioner may take it as a
safe rule, to which he will find very few exceptions, that an intermittent
fever wliich resists quinine is not 7nalajHa.
Other conditions associated with chills which may be mistaken for
pyaemia are profound ansemia, certain cases of Hodgkin's disease, the
hepatic intermittent fever associated with the lodgment of gall-stone at
the orifice of the common duct, rare cases of essential fever in nervous
women, and the intermittent fever sometimes seen in rapidly developing
cancer.
On two or three occasions I have met with intermittent pyrexia per-
sisting for weeks, in which it seemed to be impossible to give any explana-
tion of the phenomena — cases in which tuberculosis, malaria, or septicae-
mia could be almost positively excluded.
Treatment. — The treatment of septicaemia and pyaemia is largely a
surgical problem. The cases which come under the notice of the physi-
cian usually have visceral abscesses or ulcerative endocarditis, conditions
which are irremediable. We have no remedy which controls the fever.
Quinine and the new antipyretics may be tried, but they are of little serv-
ice. Quinine is probably better than antipyrin and antifebrin, which
lower the temperature for a time, but when a careful two-hourly twenty-
four-hour chart is taken, it is often found that the depression under the
influence of the drug is made up at some other period of the day ; a morn-
ing may be substituted for an afternoon fever.
The brilliant and remarkable results which follow complete evacuation
of the pus with thorough drainage give the indication for the only suc-
cessful treatment of this condition.
Unfortunately in too many cases which the physician is called upon
to treat, the region of suppuration is not accessible, and we have to be con-
tent with the employment of general measures for the support of the
patient's strength.
XVIII. CHOLERA ASIATICA.
Definition. — A specific, infectious disease, caused by the comma
bacillus of Koch, and characterized clinically by violent purging and
rapid collapse.
Historical Summary. — Cholera has been endemic in India from a
remote period, but only within the present century has it made inroads into
Europe and America. An extensive epidemic occurred in 1832, in which
year it was brought in immigrant ships from Great Britain to Quebec. It
I
nUM.i:KA ASIAI'ICA. I \u
tnivcllr.l ;ilnii;r |||.. \n\i- i ,,f iiiilTh- ii|i ( iio ( I HMit LiiliTH ; uikI (liiiilly rL*ui;hc<J
iiH lur woHt iiH i\\v iiiilitiiiy \um\H of tliu ii|i|M'r MiMHiHMi|i|ti. In thi? Miimu
yfiir it culcnMl \\\v I'liilrjl Sljitrn \ty way uf Nrw York. 'I'lu-rt? wrrt- ru-
(•iirn»H('rs (»f tlic diHriiMr in is:i.*» '.'Id. In IHIH it JMitrrrd tin? conntry
tlin>n;^'li New Oilcans, ami siucad u'iilcly up tlm Mirtriinrtippi \'ullry un«|
across I lie (((lit iiiciit lo ( 'alif<»niiii. In \s\'.t n a;4aiii appj-arcd. In ]8/)4
it was int rni|ii(«(| l»y immigrant HhipH into New York and prevailed widely
thron;;hniii I he cminlry. In ISOO and in I H(;7 there wen; leHH HeriouH epi-
demics. In is;:! ii a^^'ain appeared in llic I'nited States, Init did not pre-
vail widi'ly. In 1 ss I ilu-rc was an outbreak in I'iurope. Altlion^di oecii-
sional cases lia\c Imcii Itron^dit l)y hIuj) to tin; (pmrantine Htationn in thin
oonnliv, the disease has n(»l ;^Miiied a I'ljotiiold huru HJneo 1873.
Etiology. Ill issl Koch annoimccil the diseovery of the Hj>ecific
orL;:anism of this disease, Suhse(juent observutionn huvo confirmed his
statement that the comma bacillus, as it is termed, occurs conslantlv in
the true cholera, and in no other disease. It 1ms the form of a sli'ditly
bont nul, which is thicker, l)ut not more than ai)out half tlu» len<,'tl» (if the
tubercle bacillus, and sometimes occurs in an S-form. It is not a true
bacillus, but really a spiroclnvte. The or^'anism grows upon a great
variety of media and displays distinctive and characteristic appearances.
The bacilli arc found in the intestine, in tlie stools from tlie earliest j)eriod
of the disease, and very abundantly in the characteristic rici;- water evacu-
ations, in which they may be seen as an almost pure culture. They very
rarely occur in the vomit. Post mortem, they are found in enormous
numbers in the intestine. In acutely fatal cases they do not seem to in-
vade the intestinal wall, but in cases with a more protracted course they
are found in the follicles and even in the deeper tissues.
Modes of Infection.
((() Contagion. — It a])i)ears probable that cholera is not highly con-
tagious in the same sense as small-pox and scarlet fever, but in this respect
is very similar to typhoid fever. Physicians, nurses, and others in close
contact with the patients are not often affected. On the other hand, such
persons as washer women, who are brought into very close contact with
the cholera stools and the linen of tlie cholera patients, are particularly
prone to the disease.
(I)) Infection. — The loading authorities now agree that the disease is
propagated chiefly by the contamination of water used for drinking, wash-
ing, and cooking. It is quite possible that articles of food may be con-
taminated, particularly vegetables, such as lettuces and cresses and others,
which have been washed in infected water ; but this is probably a minor
danger in comparison with impure drinking-water. The bacilli, under
suitable circumstances — that is, when much impurity is present — may de-
velop to some extent in the water ; Koch, as is well known, found the
bacilli in a tank in India, from which the inhabitants were supplied with
wator for drinkins^ and washincr. Stroncrlv in favor of this view is the fact
9
120 SPECIFIC INFECTIOUS DISEASES.
that the virulence of an epidemic in any region is generally in direct pro-
portion to the imperfection of the water-supply. On the other hand, with
improvements and perfection in the water-works of a place, the epidemics
are reduced in intensity, and the place may even obtain immunity against
the disease. Xot only in India has the demonstration of the connection
between drinking-water and cholera infection been amply furnished, but
in England there have been many valuable illustrations. One of the most
notable of these was the celebrated Broad Street pump, in London, which
in 1854 was connected with a severe epidemic. Milk also may possibly in
some instances convey the poison.
Pettenkofer, on the other hand, denies the truth of this drinking-
water theory, and maintains that the conditions of the soil are of the
greatest importance ; particularly a certain porosity, combined with moist-
ure and contamination with organic matter, such as sewage. According
to him, the condition most favorable for the development of the virus is
found when the subsoil water is lowest. As Stille remarks : " It is more
descriptive of the fact to say that so far as cholera has in any way to do
with the condition of the soil, it is most apt to be severe and prevalent
when very dry weather follows a very wet period. Such instances are
most favorable to putrefactive fermentation and the dissemination of its
products, which thus reach wells of drinking-water and even rivers, espe-
cially when sewers empty into the water."
Pettenkofer holds that germs develop in the subsoil moisture during
the warm months, and that they rise into the atmosphere as a miasm.
The disease is always spread along the lines of human travel. In
India it has, in many notable cases, been widely spread by pilgrims. It
is carried also by caravans and in ships. It is not conveyed through the
atmosphere.
Places situated at the sea-level are more prone to the disease than
those situated inland. In high altitudes the disease does not prevail so
extensively. A high temperature favors the development of the disease,
but in Europe and America the epidemics have been chiefly in the late
summer and in the autumn.
The disease attacks persons of all ages. It is particularly prone to
attack the intemperate and those debilitated by want of food and bad sur-
roundings. Depressing emotions, such as fear, undoubtedly have a
marked influence. It is doubtful whether an attack furnishes immunity
against a second one.
Morbid Anatomy. — There are no characteristic anatomical changes
in cholera ; l)ut a post-mortem diagnosis of the nature of the disease
could be made by any competent bacteriologist, as the micro-organisms
are specific and distinctive. The body has the appearances associated
with profound collapse. There is often marked post-mortem elevation of
temperature. The rif/oi' mortis sets in early and may produce displace-
ment of the limbs. The lower jaw has been seen to move and the eyes to
(lloI.KKA ASIATK'A. )»J1
rodih'. \ iirinitM iiiovrinnits nf I In- iiriiiH iiii*! Ir^H iin^ uIno MOn. 'VUo
l»|()o<l is llii( k uinl ilarlv, iiinl llirrr '\n n miiurkiililt' (liiiiiiiiition iti tho
iiiiiniiiil of water iiihl Hills. Tlir |MTitotiii-iitii Im Htirky, uikI the coiU of
iiitcHtiiu'S an* i-oii^M'Htcii mul look lliiii and Hliriiiikfn. 'JMicri* Im iHitliin^
Hpccial ill tlu< ap|>riinui('(' of tlm HlniMucli. TIm* himiiII iiiU'Htiiif iiHiiuily
ronlaiiiH u tiirl)i(l Hcniiii, Hiiiiiiur in apiMuramr to that whirl) wan piiMM<M| in
lh(> stools. Tho iniKMtsa is, as a riih*, pair and swolhn and often (.'on^(*Ht4'd
ahoiit tlu' l*i'\rr's |)at('h('s. Post mortrni tho cpithflial lining in wjmo-
tiiiu's (iciiiKJril, iiiii this is prohahly not a (lian^a; which takoH piuci? dur-
ing life. Ill the stools, howuvor, large ninnhcrs of columnar fpithclial
cells have l)een descrihed hy many ohscM'vers. 'I'he haeilli are foinnl in
tlu» contents of the inlcKline and in thiMnucous memhrane. 'I'lie spleen
is usually small, 'i'lu' liver and kidneys may show cloudy swelling. The
heart is llahhy ; the ri<;ht chamhers are distended with hlood and the left
chamhers nvv usually empty. The lun<^s arc collapsecl, and congested at
tho hases.
The above appi'uraneea are those met with in cases which prove rapidly
fatal. \\ hen the })atient survives and death occurs during reaction, there
may ho morodelinite inllammatory appearances in the intestines and more
dollnito cliangos in tlie kidneys and liver.
Symptoms. — A period of incubation of uncertain length, probably
not more than from two to live days, precedes the develo})ment of the
symptoms.
Throe stages may bo recognized in the attack : tlie jiroliminary diar-
rbani, tho collapse stage, ami tho period of reaction.
(a) Tlie preUminarii diarrJicea may set in abruptly without any
previous indications. More commonly there are, for one or two days,
colicky pains in the abdomen, with looseness of the bowels, perhaps vom-
iting, with headache and depression of spirits. There may be no fever.
(/>) CuUapse Stage. — The diarrluoa increases, or, without any of the
preliminary symptoms, sets in with tho greatest intensity ; and profuse
liquid evacuations succeed each other rapidly. There are in some instances
griping pains and tenesmus. More commonly there is a sense of exhaus-
tion and collapse. The thirst becomes extreme, the tongue is white ;
cram})s of groat severity occur in the legs and feet. Within a few hours
vomiting sots in and becomes incessant. The patient rapidly sinks into a
condition of collapse, the features are shrunken, the skin of an ashy gray
hue, the eyeballs sink in the sockets, the nose is pinched, the cheeks are
hollow, the voice becomes husky, the extremities are cyanosed, and the
skin is shrivelled, wrinkled, and covered with a clammy perspiration. The
temperature sinks. In the axilla or in the mouth it may be from five to
ten degrees below normal, but in the rectum and in the internal parts it
may be 103° or 104°. The pulse becomes extremely feeble and flickering,
and the patient gradually passes into a condition of coma, though con-
sciousness is often retained until near the end.
122 SPECIFIC INFECTIOUS DISEASES.
Tlie f.Tces are at first yellowish in color, from the bile pigment, but
soon they become grayish white and look like turbid whey or rice-water ;
whence the term " rice-water stools." There are found in it numerous
small flakes of mucus and granular matter, and at times blood. The
reaction is usually alkaline. The fluid contains albumen and the chief
mineral ingredient is chloride of sodium. Microscopically, mucus and
epithelial cells and innumerable bacteria are seen, the majority of the
latter being the comma bacilli.
The condition of the patient is largely the result of the concentration
of the blood consequent upon the loss of serum in the stools. There is
almost complete arrest of secretion, particularly of the saliva and the
urine. On the other hand, the sweat-glands increase in activity, and in
nursino: women it has been stated that the lacteal flow is unaffected.
This stage may not last more than two or three hours, but more com-
monly lasts from twelve to twenty-four. There are instances in which
the patient dies before purging begins — the so-called cholera sicca.
{c) Beaction Stage. — When the patient survives the collapse, the
cyanosis gradually disappears, the warmth returns to the skin, which may
have for a time a mottled color or present a definite erythematous rash.
The heart's action becomes stronger, the urine increases in quantity, the
irritability of the stomach disappears, the stools are at longer intervals,
and there is no abdominal pain. In the reaction the temperature may
not rise above normal. Kot infrequently this favorable reaction is inter-
rupted by a recurrence of severe diarrhoea and the patient is carried off in
a relapse. Other cases pass into the condition of wdiat has been called
cliolera-typhoid., a state in which the patient is delirious, the pulse raj^id
and feeble, and the tongue dry. Death finally occurs with coma. These
symptoms have been attributed to uraemia.
During epidemics attacks are found of all grades of severity. There
are cases of diarrha?a with griping pains, liquid, copious stools, vomiting,
and cramps, with slight collapse. The term cholerine has been applied to
these cases. They resemble the milder cases of cholera nostras. At the
opposite end of the series there are the instances of cholera sicca, in which
death may occur in a few hours after the attack, without diarrhoea. There
are cases also in which the patients are overwhelmed with the poison and
die comatose, without the preliminary stage of collapse.
Complications and Sequelae. — The typhoid condition has al-
ready been referred to. The consecutive nephritis rarely induces dropsy.
Diphtheritic colitis has been described. There is a special tendency to
diphtheritic inflammation of the mucous membranes, particularly of the
throat and genitals. Pneumonia and pleurisy may develop, and destruc-
tive abscesses may occur in different parts. Suppurative parotitis is not
very uncommon. In rare instances local gangrene may develop. A
troublesome symptom of convalescence may be cramps in the muscles of
the arms and legs.
CIlnl.KKA ASIATK'A. l^.'J
Dia^^nosiB. Tin' culy allcj'lKHi willi wliirli AMiutic cholmi roiiM l>«
(•(Hiroiiii<l((| is itir r/i(i/rr(f //o.v//vM, t lio M<<v<T« cliolrriiif: (liurrlidii wliicli
occiiis (liii'iii^^ llir Hiiiiiiiirr iiioiitliH ill tciiipcniti? cliniutrM. 'I'lic dinicul
|ii(-liii-(' i^\' llir two alVcctiniiH in idciiticul. '\\w cxtrciiM) collupiM;, voiiiititi^,
mid I icc-wutrr hIooIm, tim crjuiipH, tin? cyaiioHiMl iippniniiwo, ure all m-vii in
tlu' worHl foriiiM (if clinlcni iioslruH. In <'iif<M'l»lr(l pcrHoriH di-jitli may
occur within twelve hours. It is of ccmrsu cxtrcnu'ly inijMirtant to Ih»
ahic t(» (liaLTiiost' between the two alTeetiouH. Tliis can only he <lo?i(? hy
one thoroii^dilv \cisr(l ill Imeteriolo^ical nu-tliods, and (!onv('rHant with the
div(«rsilie(l ll(»i:i (if the inti'stines. The eoninia hacilluH in present in thu
dejections of a ^neat majority of the cases and can 1)0 Been on cover-^Ias.^
preparations. ThoiiLrh the eye of the expert may h<* a})le to dilTerentiatir
lictween thi^ bacillus of true cholera ami that which occurs in cholera
nostras, cultures should he made, from which alone poHitivo resultd can bo
obtained.
Attacks very similar to Asiatic chok'ra are ]>rodnced in poisoning by
arsenic, corrosivo sublimate, and certain fun^d ; but a diHiculty in diair-
nosis could scarcely arise.
The pr()(/u()sis is always uncertain, as the mortality ranges in different
epidemics from 'M) to 80 per cent. Intemjx'rance, debility, and old ago
are unfavorable conditions. The more i-aj)idly the collapse sets in, tho
greater is tho danger. Cases with marked cyanosis and very low tempera-
ture rjirely recover.
Prophylaxis. — Preventive measures are all-im])ortant, and isolation
of the sick and ihorougli disinfection have eU'ectually prevented the dis-
ease entering England or the United States since 18T3. On several occa-
sions since that date, cholera has been brought to various ports in Amer-
ica, but has been checked at quarantine. During epidemics the greatest
care should be exercised in the disinfection of the stools and linen of the
patients. AVhen an epidemic prevails, persons should be "warned not to
drink water unless previously boiled. Errors in diet should be avoided.
As the disease is not more contagious than typhoid fever, the chance of a
person passing safely through an epidemic depends very much upon how-
far he is able to carry out thoroughly prophylactic measures. Digestive
disturbances are to be treated promptly, and particularly the diarrha?a,
■which so often is a preliminary symptom. For this opium and acetate of
lead and large doses of bismuth should be given.
Attempts have been made to procure a protective virus. During the
last epidemic in Europe, Ferran, in Spain, made a large number of inocu-
lations which were chiimed to be protective; but the French commission
reported adversely against these claims. Shakespeare* seemed to have
been more favorably impressed. Both Gamaleia and Lowenthal have ren-
* Report on Cholera in Europe and India. By E. 0. Shakespeare, United States
Commissioner. Washington, 1891.
124 SPECIFIC INFECTIOUS DISEASES.
dered animals immune against the cholera virus, but it is not probable
that the method which they employ would be available for man.
Medicinal Treatment. — During the initial stage, when the diar-
rha?a is not excessive but the abdominal pain is marked, opium is the most
efficient remedy, and it should be given hypodermically as morphia. It
is advisable to give at once a full dose, which may be repeated on the
return of the pain. It is best not to attempt to give remedies by the
mouth, as they disturb the stomach. Ice should be given, and brandy or
hot coffee. In the collapse stage, writers speak strongly against the use
of opium. Undoubtedly it must be given with caution, but, judging from
its effects in cholera nostras, I should say that collapse per se was not a
contra-indication. For the intense thirst the patient may be given ice-
water, of which he should be allowed to drink freely. The vomiting is
very difficult to check. In severe cases creosote, hydrocyanic acid, and
other remedies seem quite ineifectual.
Salol has been warmly recommended as capable of preventing the de-
velopment of the bacilli in the intestine.
External applications of heat should be made and a hot bath may be
tried. Warm applications to the abdomen are very grateful. Hypodermic
injections of ether will be found serviceable.
Judging from the success which has followed the copious enemata in
cholera infantum^ this practice should be tried. Two or three pints of
water should be allowed to flow slowly into the rectum. If the hips are
elevated it may be retained for some time, but is usually rapidly ejected.
The water may be given either cold or warm ; probably the latter would
be better. During the last epidemic in Italy, Cantani used this method,
which he calls enter ocly sis ^ with great success. In each injection he gave
tannic acid and, generally, laudanum.
Owing to the profuse serous discharges the blood becomes concen-
trated, and absorption takes place rapidly from the lymph-spaces. This
it is which gives the shrunken puckered appearance to the features and
skin of a patient in the collapse stage. To meet this, intravenous injec-
tions have been practised. My preceptor, Bovell, first practised the intra-
venous injections of milk in Toronto, in the epidemic of 1854. Less risky
and equally efficacious is the subcutaneous injection of a saline solution.
For this common salt should be used in the proportion of about four
grammes to the litre. With rubber tubing, a canula from an aspirator,
or even with a hypodermic needle, the warm solution may be allowed to
run by pressure beneath the skin. It is rapidly absorbed, and the process
may be continued until the pulse shows some sign of improvement. This
is really a valuable method, thoroughly physiological, and should be tried
in all severe cases.
In the stage of reaction special pains should be taken to regulate the
diet and to guard against recurrences of the severe diarrhoea.
VKI^LoW KKVKIt. 126
XIX. YELLOW FEVER.
Doflnition. — Am miih* friuilr iliHriixii^ of tropicjil luid Miibtropicul
(U)iiiitri(^s, (*lmnu'tori/.('<l by jiiiiMili<'u and lia'iiiorrlm^M'H, and duo U> the
a(^ti(>ii of a .Mpccilic viruH, tlio naturo of which in yi't iiiikriown.
Etiolop^y. — 'I'h«* disease prrviiils eiKh-rnically in the \N est Iiidien and
in eerlain seclionHof the Spanish Main. I'Voni tljese re^'ioiiH it ocrejwionally
extends and, under sui(al)h' conditions, prevails epidemically in tlnr Southern
States. Now and I hen it is hrou^lit to the lar^e seaportH of the; Atlantic
coast. Konnerly it o(<iirred extenHively in the United StateH. In the
hitter pari of the last century and the beginning of this, frightful epi-
(h'lnics prevailed in Philadelphia and other Northern cities. 'I'he epidemic
of 17'.K{, so graphically described by Matthew Carey, was the mf>.st serioUH
that has over pri'vailed in any city of the Middle States. The mortality,
as given by Carey, during the months of August, September, October, and
November, was 4,041, of whom iJ,435 died in the months of September and
October. The popuhition of the city at the time was only 4(>,()0(). Epidem-
ics occurred in the United States in 171)7, 17U8, 17'J'J, and in l8(>-^\ when
the disease prevailed slightly in Boston and extensively in lialtimore. In
1803 and 1805 it again appeared ; then for many years the outbreaks were
slight and localized. In 1853 the disease raged throughout the Southern
States. In New Orleans alone there was a mortality of nearly eight thou-
sand. In 18()7 and 1873 there were moderately severe epidemics. In
1878 the last extensive epidemic occurred, chiefly in Louisiana, Alabama,
and Mississippi. The total mortality was nearly sixteen thousand. In
Europe it hiis occasionally gained a foothold, but there have been no
wide-spread epidemics except in the Spanish ports. The disease exists on
the west coast of Africa. It is sometimes carried to ports in Great Britain
and France, but it has never extended into those countries. The history
of the disease and its general symptomatology are exhaustively treated in
the classical work of Kene La Roche.
Guitoras recognizes three areas of infection : (1) The focal zone in
which the disease is never absent, including Havana, Vera Cruz, Rio, and
other Spanish-American ports. (*2) Perifocal zone or regions of periodic
epidemics, including the ports of the tropical Atlantic in America and
Africa. (3) The zone of accidental epidemics, between the parallels of
45° north and 35° south latitude.
The epidemics are invariably due to the introduction of the poison
either by patients affected with the disease or through infected articles.
Unquestionably the poison may be conveyed by fomites. Individuals of
all ages and races are attacked. The negro is much less susceptible than
the white, but he does not enjoy an immunity. Residents in southern
countries, in which the disease is prevalent, are not so susceptible as stran-
gers and temporary residents. Males are more frequently affected and the
mortality is greater among them, owing probably to greater exposure.
126 SPECIFIC INFECTIOUS DISEASES.
Very young children usually escape ; but in the epidemics of large
cities the number under five attacked is large, since they constitute a con-
siderable proportion of the population un2)rotected by previous attack.
Guiteras states that the " foci of endemicity of yellow fever are essentially
maintained by the Creole infant population." Immunity is acquired by
passing through an attack or by prolonged residence in a locality in which
it is endemic. The statement so often made that the Creoles are exempt
from yellow fever has been abundantly disproved. They certainly are not
so susceptible, but in severe epidemics they die in numbers. The evidence
in favor of inherited immunity is not conclusive.
Conditions favoring the Development of Epidemics. — Yellow fever is
a disease of the sea-coast, and rarely prevails in regions with an eleva-
tion above one thousand feet. Its ravages are most serious in cities, par-
ticularly when the sanitary conditions are unfavorable. It is always most
severe in the badly drained, unhealthy portions of a city, where the popu-
lation is crowded together in ill-ventilated, badly drained houses. The
disease prevails during the hot season. In Havana the death-rate is great-
est during the months of June, July, and August. The epidemics in the
United States have always been in the summer and autumn months.
The specific germ of the disease has not y^et been discovered. Stern-
berg, in his last report to the United States Government, concludes that
the specific cause of yellow fever has not yet been demonstrated. With
this statement Cornil and Babes * agree, and they do not accept the organ-
isms described by Freire, Carmona, and Gibier.
Morbid Anatomy. — The skin is more or less jaundiced. Cutane-
ous hemorrhages may be present. No specific or distinctive internal
lesions have been found. The blood-serum contains haemoglobin, owing
to destruction of the red cells, just as in pernicious malaria. The 'heart
sometimes, not invariably, shows fatty change ; the stomach presents more
or less hyperaemia of the mucosa with catarrhal swelling. It contains the
material which, ejected during life, is known as the Uach vomit. The
essential ingredient in this is transformed blood-pigment. In the two
specimens which I have had an opportunity of examining it differed in no
respect from the material found in other affections associated with haema-
temesis. There is no proof that this black material depends upon the
growth of a micro-organism. The liver is usually of a pale yellow or
brownish-yellow color, and the cells are in various stages of fatty degen-
eration. From the date of Louis's observations at Gibraltar in 1828, the
appearances of this organ have been very carefully studied, and some have
thought the changes in it to be characteristic. Councilman has described
remarkable appearances in the liver-cells which he believes are distinctive
and peculiar. Fatty degeneration and regions of necrosis are present in
all cases. The kidneys often show traces of diffuse nephritis. The epi-
Les Bacteries, 1890.
VKI.LnW ri'lVKIt. 127
llirliiim of (ho oouvoliitcil liihulrH lA Hwollrn urnl vrry ^'niiiuliir; tlioro
miiy ulso 1)0 nocroiic clmu^cM. In \ut\\\ liver und kiilmv-t l(ii''t<ria nf vjiri-
oiis Moi'ts Imvo Im'oh <loMorilMM|.
Symptoms. 'I'lic inciihatinn in MHiially tlin-o or four duvH, but it
may l)tMoss I li;iii Iwciily-foiir hours and prolonged to Hoven diiVH. Tho
oiis(>t in Kud(h'ii ; as ii rido, without pnliiMinary HVinptoiiiH. An initial
chill JM (*oiniMoii, and with it aro UHually associated hca<lachc and pairiM in
the hack and lind>s. 'i'lic fever rises rapidly and the skin feeln very }»ot
and dry. The face is tlushe(| ; the ton;^MU' fnrre<l, hut rnoiKt; the throat
sore. Nausea and voiuitini^ are present, and hucome more intcriHi* on
tho second or lliird day. 'V\\r. howels ar(? usually constipatiMl. The
urine is reduced in amount and nuiy he alhuminous from tlu' outs^'t.
'I'lu» pulse, at lii-sl, has the usual fehrile (diaracters, hut rpiickly In'come.s
feehle and, as the jaundice develops, may hecoine slow. 'J'his sta^^; of
invasion, or (he frhri/r sfaijCy lasts from a few hours to two or three
days. It is succecdiMl hy a remission, oi-, as it has sometimes been called,
the sfiKir of rtiini^ duriiiL,^ which (he (eniperaturo falls and the sever-
ity of tho symp(oms abates. In favorable cases the fever now subsides
and convalescence se(s in. In sucb cases jaundice may not develop.
In (he (bird stage, or (hat of tbe fehrile reactian^ the temperature rises
again and tbo symptoms become aggravated. The jaundice develops
rapidly, the vomiting increases, and, in a considerable proportion of the
cases, black vomit occurs. This consists of blood and gastric mucus
altered by tho acid juices of tbe stomacb. Thougb usually regarded as
di8(inctive and characteristic of the disease, material identicjd with it is
brougbt up under other febrile conditions in wbicli vomiting of blood
occurs. Altered blood-corpuscles, epitbelial cells, portions of food, and
various fungi are found in tbe fluid. Tbe vomiting may be accompanied
by great abdominal pain. Tbe stools are often tarry from tbe presence of
altered blood. In mild cases tbe vomitinix ceases durinfj tbe first stajire of
tbe disease. Black vomit is not necessarily a fatal symptom, thougb it is
present only in tbe severer cases of tbe disease. Jaundice occurs in a
limited number of tbe cases which recover, and is present in almost all the
fatal cases. From the character of the disease it is probably hiematoge-
nous in its origin. Bleeding may occur from the kidneys or from the gums,
and hfemorrhages into the skin are not uncommon. As would be expected
in a fever of this nature, the urine is albuminous ; the amount varvinor ;i
good deal with the intensity of the fever, and with the grade of jaundice.
Febrile icterus, from whatever cause, is almost invariably associated with
albuminuria and tube-casts, and the evidences of a diffuse nephritis.
Relapses occasionally occur. Among the varieties of the disease it is
important to recognize the mild cases. These are characterized by slight
fever, continuing for one or two days, and succeeded by a rapid convales-
cence. Such cases would not be recognized as yellow fever in the absence
of a prevailing epidemic. Cases of greater severity have high fever and
128 SPECIFIC INFECTIOUS DISEASES.
the features of the disease are well marked — vomiting, prostration, and
hagmorrhages. And lastly there are malignant cases in which the patient
is overwhelmed by the intensity of the fever, and death takes place in two
or three days.
In severe cases convalescence may be complicated by the occurrence of
parotitis, abscesses in various parts of the body, and diarrhoea. An attack
confers an immunity which persists, as a rule, through life.
Diagnosis. — Mild cases, and even severe cases in the early period of
an epidemic, are very difficult to recognize. The disease simulates closely,
and may be mistaken for ordinary malarial remittent fever. It is not un-
common for physicians, in regions in which yellow fever is occasionally
epidemic, to call the milder cases malarial fever, reserving the name of
yellow fever for the severer forms with jaundice and black vomit. The
only disease with which these cases could be confounded is malaria in
its remittent and pernicious forms. But yellow fever can now be defi-
nitely and at once separated by the examination of the blood. Twice
in Philadelphia I was sent for to determine whether a patient, freshly
arrived in the city from the South, had yellow fever or pernicious mala-
ria ; and I was able in both instances, by finding Lavaran's organisms in
the blood, to pronounce definitely upon the nature of the disease. The
clinical picture in certain cases of malarial remittent and yellow fever
may be almost identical. The presence of albumen in the urine, upon
which some writers lay such stress as a distinguishing feature in yellow
fever, is far too common a symptom in all forms of malaria to be worth
much as a guide. Guiteras states that there may be difficulty for a time
in recognizing the difference between mild cases of thermic fever and
yellow fever.
Prognosis. — In its graver forms, yellow fever is one of the most
fatal of epidemic diseases. The mortality has ranged, in various epidem-
ics, from 15 to 85 per cent. In heavy drinkers and those who have been
exposed to hardships the death-rate is much higher than among the bet-
ter classes. In the epidemic of 1878, in New Orleans, while the mortality
in hospitals was over 50 per cent of the white and 21 per cent of the col-
ored patients, in private practice the mortality was not more than 10 per
cent among the white patients. Favorable symptoms are a low grade of
fever, sliglit jaundice, absence of haemorrhages, and a free secretion of
urine? If the temperature rises above 103° or 104° during the first two
days, the outlook is serious. Black vomit is not an invariably fatal symp-
tom. Cases with suppression of urine, delirium, coma, and convulsions
rarely recover.
Prophylaxis. — The measures to be taken are —
(a) " Exclusion of the exotic germ of the disease by the sanitary super-
vision, at the port of departure, of ships sailing from infected ports, and
thorough disinfection at the port of arrival, when there is evidence or rea-
sonable suspicion that they are infected ; (b) isolation of the sick on ship-
YKIJ.nw I r.VKIt. 120
hoard, 111. (nmniMtin(» HtatioiiH, ami, ho far iih prarll»'al»lr, in rwrntly ii»f«"«''!
platcM; {(•) (lisiiifcrlinM of fXi'n-ta, ami of the «'loiliiii^' aii<l l><'«l«lii»^ n • i
l)y \\\o MJck, and of localiticH into whicli nwoH liiivo hocii intnxliHMjtl, or
wliirh liavt' lu'cniiic iiifccird ill any way; (i/) d«'jM»jiulalioii of inf«Mrt4Ml
plact^M- i. •'., i1h« nimisal of all siiHccptildo |H.THonH wliorto pruikJiicc iif not
iiocoHsary for llic rarr of \\\v sick" (SUtijIut^')- Hurini^' an opidmiir,
individuals who must rcnniin in the hx-aiity HhoiiM jivoid thi? rf^^ionn in
wiiii'h till' diH('as(> prevails nn»st ; they should live temperately, avoidin;,' all
oxeossos, ami shotdd \h^ careful not to ^ot ovorheated, either in tho Hun or
by oxorcuso. It is very douhifiil whether (he prevuntivo inoculationH in-
troductMl hy iMcirc in Urazil and Carniona in Mexico are of any value.
Treatment. — Careful nursin;,' and a symptomatic plan of tn-atment
prol)ai)!v i^ive Iht^ hcst results. Bleeding' has lon^' since heen ahandoned.
ilow mucli patients will stand in this disease is illustrated by UuHh'H pra<>
tico, which was of the most heroic character. Ho says: *' From a newly
arrived Kniijlishniaii 1 took 111 ounces, at twelve bleedings, in six days;
four were in twenty-four hours. 1 (^avc within the course of the same six
days nearly IT)!) grains of calomel, with the usual pro})orti()ns of jalap and
<:!;amboi:^o " * ^V it h tho courage of his convictions this modern Sangrado
himself submitted to two bleedings in one day, and had his infant of six
weeks old bled twice. Neither emetics nor purgatives are now employed.
Of special remedies quinine is warmly recommended, and, when hamior-
rhage sets in, the perchloride of iron. Digitalis, aconite, and jaborandi
have been employed. Sternberg advises the following mixture : Bicar-
bonate of soda, 150 grains ; bichloride of mercury, J grain ; pure water,
1 quart. Three tablespoonfuls to be given every hour. This is given on
the view that the specific agent is in the intestine, and that its growth may
possibly be restrained by this antacid and antiseptic mixture. The fever
is best treated by hydrotherapy. There are several reports of the good
elfects of cold baths, sponging, and the application of ice-cold water to
the head and the extremities in this disease. Vomiting is a very difficult
symptom to control. Morphia hypodermically and ice in small quantities
are probably the best remedies. Medicines given by the mouth for this
purpose are said to be rarely efficacious.
We have no reliable medicine which can be depended upon to check
the haMiiorrhages. Ergot and acetate of lead and opium are recommended.
The unvmic symptoms are best treated by the hot bath. Stimulants should
be given freely during the second stage, when the heart's action becomes
feeble and there is a tendency to collapse. The patient should be carefully
fed ; but when the vomiting is incessant it is best not to irritate the stom-
ach, but to give nutritive enemata until the gastric irritation is allayed.
* Manuscript letter to Redman Coxe.
130 SPECIFIC INFECTIOUS DISEASES.
XX. DYSENTERY.
Definition. — Under this clinical term several different forms of in-
testinal flux are described, which are characterized by frequent stools, and
in the acute stage are accompanied by tormina and tenesmus. Anatomi-
cally there are inflammation and usually ulceration of the large bowel.
Etiology. — Dysentery is one of the four great epidemic diseases of
the world. In the tropics it destroys more lives than cholera, and it has
been more fatal to armies than powder and shot.
While especially severe in the tropics, sporadic cases constantly occur
in more temperate climates, and under favoring circumstances epidemics
are found even in the more northern countries, such as Canada and Nor-
way. It has become less frequent of late years, OAving to improved sani-
tary conditions. The statistics of the Montreal General Hospital, for the
twenty years ending May 1, 1889, show a remarkable decrease in the dis-
ease. In the decade ending May, 1879, 150 cases were admitted ; whereas
in the last ten years there have been only 31 cases admitted. There has
been a similar decrease at the Pennsylvania Hospital.
In the Southern cities of this country dysentery is more prevalent ; even
when not epidemic, sporadic cases are common. In Baltimore it prevails
every summer, and has on several occasions been epidemic.
Epidemics of dysentery have occurred in the United States for more
than a century, and Woodward has collected the data which show the
various outbreaks. Perhaps the most serious was that which prevailed in
various localities from 1847 to 1856. During the war of secession the dis-
ease existed to an alarming extent in both armies. According to Wood-
ward's report,* there were in the Federal service in all 259,071 cases of
acute and 28,451 cases of chronic dysentery. Probably a considerable pro-
portion of the 182,586 cases of chronic diarrhoea should also come in this
category. The decennial census reports since 1850 show a progressive de-
crease in the total number of deaths from this disease. It prevails most
extensively in the summer and autumn. Sudden changes of temperature
appear more harmful than variations in moisture. The effluvia from de-
composing animal matter have been thought by some to predispose to or
even to cause the disease. That dysenteric affections are more frequent
in malarial localities has long been known, and is probably connected with
external conditions favoring their development. With reference to the
influence of drinking-water. Woodward is doubtless correct in stating that
the effects of dissolved mineral matters have been greatly exaggerated.
On the other hand, from the days of the old Greek physicians, it has been
held that the impurities in the stagnant water of marshy districts and
* Medical .and Surgical History of the War of the Rebellion. Medical, vol. ii ; the
most exhaustive treatise extant on intestinal fluxes — an endunng monument to the in-
dustry and ability of the author.
DVSK.NTKUV. \'M
])()n(lM iimv ^'ivo r\nv to <liiirilnrji ami <lyHrnUTy. IIiTo, Ijowovcr, it in jirob-
ul)Iy iiol llio vc'^'ctahlr iinpiiritirH wliirli aro diroclly caUMutivr, hut tlio or-
ganic iii.'iiici- iriitlci'H tlir water a iimrr favora)>l() iiUMliiitii for tin; (Jev(.*lo|>-
inciil. of or;,niiiisinH wliicli may <'hiih»i diMniHc.
DvMpcplic coiHlilioiiM, particularly thonn <'jmMr<l hy tlic iu^rwtion *>f lia<l
food aiul unripe fiMiit, seem to predinpom? to i\w iVinviiMi. iirviil tiln'HH luix
hwu liiid i»v (iciiiian aiithoritiuH on thu iiuporUin(!o of conHtipulioii lu a,
(Miiisul factor in dysentery.
Dysentery occurs at all a^'cs. M'hcrc is no mce ininiuiiity. 'I'lie con-
taiifioMSMess of tlu< disease is doul)tful. 'i'ho cxperienct; of tlu; civil war
is decidedly aii:ainsl it, hut tlu; possihility, as with typhoid fuvt-T, iiiUHt ho
acknowlcdii^ed.
Clinical Forms, ((f) Acute Catarrhal Dysentery. —'I'his nuiy occur
sporadically or endcMiiically, iind is the varii'ty most frcfpieiitly found in
toniporatc climates.
Marhid Antthnntj. — 'I'iio lesions aro confinod to tlie hir^o howcl, and
sometimes tlu» ileum also is involved. The mucous memhranu is injected,
swollen, and often covered with tenacious hlood-stained nmcus. 'J'hc
most strikini]^ feature is the enlari^ement of tlu; solitary follicles, which
stand out })romin(Milly from tiie mucous memhrane. In very acute
forms, as in child i-cn, tlu^ picture is that of an acute follicular colitis. In
more protracted cases the follicles sup])urate or are capped with an area
of necrotic tissue. In other instances the slouij^hs have separated and the
entire colon presents numerous ulcers, most of which have developed from
the follicles, and others have resulted from uecrosia and sloughing of the
intervening tissue.
Sytuptoms. — There maybe preliminary d3'spepsia or slight pains in the
abdomen. Chills are rare. Diarrluva is the most constant initial symp-
tom, and at first is not painful. Usually within thirty-six hours the char-
acteristic features of the disease develop — abdominal pain of a colicky,
griping character, frequent stools, which are passed with straining and
tenesmus ; the constitutional disturbance is variable, and in mild cases
may be slight. The temperature range is not high, but at the outset the
fever may rise to 102° or 103°. The tongue is furred and moist, and as
the disease progresses becomes red and glazed. Nausea and vomiting may
be present, but as a rule the patient retains nourishment. The constant
desire to go to stool and the straining or tenesmus are the most distressing
symptoms. The abdomen may be flat and hard. The thirst is often exces-
sive. The stools in this variety of dysentery have the following characters :
During the first twenty-four or forty-eight hours they consist of more or
less clear mucus and blood mixed with small fi>?cal scybala. After this they
become purely gelatinous and bloody, and are small and frequent, from
fifteen to two hundred in twenty-four hours, according to the severity of
the case. About the end of the first week the mucus becomes opaque, the
proportion of blood diminishes, and grayish or brownish shreddy material
132 SPECIFIC INFECTIOUS DISEASES.
appears in the stools, which become gradually reduced in frequency.
Some of the stools at this time may be wholly composed of a greenish pul-
taceous material and mucus. As the disease subsides, faecal matter again
appears in the stools, increasing in amount until fully formed faeces are
passed, containing no mucus or blood. Microscopical examination of the
glairy bloody stools shoAvs red blood-corpuscles, few or many leucocytes,
and constantly large, swollen, round or oval epithelioid cells, containing
fat-drops and vacuoles. Bacteria are scarce ; occasionally the cercomonas
intestinalis is seen in large numbers.
Course of the Disease. — The milder cases run a course, as Flint has
shown, of about eight days ; severer ones rarely terminate within four
weeks. Eecovery may be imperfect, and the affection occasionally be-
comes chronic. In this form the complications are not numerous; peri-
tonitis and liver abscess are extremely rare. Except in young children, a
majority of the cases terminate favorably.
{b) Tropical Dysentery— Amoebic Dysentery. — This form of intestinal
flux is characterized by irregular diarrhoea and the constant presence in the
stools of the ammha coll (Losch), amceba dysenterm (Councilman and La-
fleur). It is this variety which prevails extensively in the tropical and sub-
tropical regions, and which proves so fatal in epidemic form. The amceba
is a unicellular, protoplasmic, motile organism, from ten to twenty micro-
millimetres in diameter, consisting of a clear outer zone, ectosarc, and a
granular inner zone, endosarc, containing a nucleus and one or more
vacuoles. It was first described by Lambl in 1859, and subsequently by
Losch, who considered it the cause of the disease. In the endemic dysen-
tery of Egypt, Kartulis, in 1883, found these amoebae constantly in the
stools, in the intestines, and in the liver abscesses. He was afterward
enabled to cultivate them in straw infusion, and to produce the disease
artificially in cats and dogs. In 1890 I reported a case of dysentery with
abscess of the liver originating in Panama, in which the amoebae were
found in the stools and in the pus from the abscess ; and lately Council-
man and Lafleur* have described the clinical features and anatomical
lesions in a series of cases of this form of dysentery in my wards. Dock,
in Galveston, has demonstrated their presence in a number of cases, and
Musser has found them in Philadelphia. The disease is very common in
tropical and subtropical countries. It is, however, found more or less
widely distributed throughout Europe and North America. The sources
of infection are not known, but it seems probable that one of them is
drinking-water.
Morbid Anatoivy. — The lesions are found in the large intestine, some-
times in the lower portion of the ileum. Abscess of the liver is a common
sequence. Perforation into the right lung is not infrequent.
Intestines. — The lesions consist of ulceration, produced by preceding
Johns Hopkins Hospital Reports, vol. ii.
DVSr.NTKKV. 133
iiillllriitioii, ;.'rii(ial nr inral, of tlio HiilitiiucoHU, llio {(ctifriil iiitiltrution
Ixiii;^' due to an (I'dciiiittniiM cniiditioi), tlio local to iiiiilti)ili('UlioM of tho
lix(Ml (tells of Lho tiHHiK*. Ill tho i'lu'licrit Htii^c tlicM' hx'iil iiitiitriitioiii
a|i|i('ur us licmisjtlM'ricjil clrviitionH iilmvo tlw ^'riwnil \v\v\ of tin- riiiicoHU.
'i'lu' niucoiiM iiirmliijuu) over tlu'si' hooii Iumoiiu'h necrotic aiwl in eant olT,
exjMJsin;^ \\w iiilill rated HwbmiieoiiH tirtHue iiM ii ^'niyiMli-yellow pdatinoui
II121SS, whi<-li at tirsi foiiiis tin; tloor of thu ulcer, l)Ut U HubHi>()ueiitly ciMt
olT )iH u k1oii;(1i.
The iiuli\ idiiai ulcerrt are round, oval, or irre^^Milar, wilh uihllrated,
undenniut'il edicts, 'i'he visihh» api-rture is often Hrnall coriij>ared to the
loss of tissiu' lieMealii it, the ulcers underujinin;^ the niuco.-a, coalt'w:ing,
and forming sinuous tracts l)ridged over hy apparently normal rnucoua
nuMuhraiu'. Accord iiiiT to tiie stage at whi(di the lesiouH arc ohnerved, tho
tloor of the ulcci- may l»e formed l)y tlie suhmucous, tho muscular, or the
serous coat of the intestine. 'J'he ulceration may alTect the whole or Komc
portion oidy of the large intestine, j)articularly the ca'cum, thc^ hepatic
anil sigmoid tlexures, and the rectum. In severe cases the whole of tlio
intestine is niucli thickened and riddled with ulcers, with only here and
there islands of intact mucous membrane.
The disease advances by progressive infiltration of the connective-tissue
layers of the intestine, which })roduces necrosis of the overlying structures.
Thus, in severe cases there may be in ditTerent parts of the bowel slough-
ing VN masse of the mucosa or of the muscularis, and tlie same process is
observed, but not so conspicuously, in the less severe forms.
In some cases a secondary diphtheritic intlammation complicates the
original lesions.
Healing takes place by the gradual formation of fibrous tissue in the
tloor and at the edges of the ulcers, which may ultimately result in partial
and irregular strictures of the bowel.
Microscopical examination shows a notable absence of the products of
purulent inflammation. In the infiltrated tissues poly nuclear leucocytes
are seldom found, and never constitute purulent collections. On the
other hand, there is proliferation of the fixed connective-tissue cells.
Anux^biv are found more or less abundantly in the tissues at the base of
and around the ulcers, in the lymphatic spaces, and occasionally in the
blood-vessels.
The lesions in the liver are of two kinds : firstly, local necroses of the
parenchyma, scattered throughout the liver and possibly due to the action
of chemical products of the ama^ba^ ; and, secondly, abscesses. These may
be single or multiple. When single they are generally in the right lobe,
either toward the convex surface near its diaphragmatic attachment, or on
the concave surface in proximity to the bowel. Multiple abscesses are
small and generally superficial. In an early stage the abscesses are grayish-
yellow, with sharply defined contours, and contain a spongy necrotic ma-
terial, with more or less fluid in its interstices. The larger abscesses have
134 SPECIFIC INFECTIOUS DISEASES.
ragged necrotic walls, and contain a more or less viscid, greenish-yellow
or reddish-yellow pnrulent material mixed with blood and shreds of liver-
tissue. The older abscesses have fibrous walls of a dense, almost carti-
laginous toughness. A section of the abscess wall shows an inner necrotic
zone, a middle zone in which there is great proliferation of the connective-
tissue cells and compression and atrophy of the liver-cells, and an outer
zone of intense hyperaemia. There is the samo absence of purulent inflam-
mation as in the intestine, except in those cases in which a secondary in-
fection with pyogenic organisms has taken place. The material from the
abscess cavity shows chiefly fatty and granular detritus, few cellular ele-
ments, and more or less numerous amoebae. Amoebae are also found in the
abscess walls, chiefly in the inner necrotic zone. Cultures are usually
sterile. Lesions in the lungs are seen when an abscess of the liver — as so
frequently happens — points toward the diaphragm and extends by conti-
nuity through it into the lower lobe of the right lung. The gross and
microscopical appearances are similar to those of the liver.
Symptoms. — The onset may be sudden, as in catarrhal dysentery, or
gradual, beginning as a trifling and perhaps transient diarrhoea. In severe
gangrenous cases the abrupt onset is more common. The subsequent
course is a very irregular diarrhoea, marked by exacerbations and inter-
missions, and progressive loss of strength and flesh. There is moderate
fever as a rule, but many cases are afebrile throughout the greater part of
their course. Abdominal pain and tenesmus are frequently present at the
onset, especially in severe cases, but may be entirely absent, and vomiting
and nausea are only occasionally observed. The stools vary very much in
frequency and appearance in different cases and at different periods in the
same cases. They may be very frequent, bloody, and mucoid at the out-
set, as in catarrhal dysentery; but their main characteristic, when the
disease is well established, is fluidity. From six to twelve yellowish-gray
liquid stools, containing mucus and occasionally blood in varying propor-
tions, are passed daily for weeks. Actively moving amoebae are found in
these stools, more abundantly during exacerbations of the diarrhoea, and
disappear gradually as the stools become formed.
Abscess of the liver, and especially of the liver and lung, is a frequent
and formidable complication. In India it occurs once in every four or
five cases.
The duration of the disease in uncomplicated cases varies from six to
twelve weeks. Recovery is tedious, owing to anaemia and muscular weak-
ness, often delayed by relapses, and there is in all cases a constant tend-
ency to chronicity. The mortality is much higher than in catarrhal
dysentery. A fatal issue is due cither to the initial gravity of the intes-
tinal lesions, to exhaustion in prolonged cases, or to involvement of the
liver.
(c) Diphtheritic Dysentery. — A form of colitis or entero-colitis in
which areas of necrosis occur in the mucous membranes, which on sepa-
DVSKNTKUV. l.'Jfj
nition lc;ivr ulcers. 'I'liin occnrM : (//) Ah h jninutrtf diwiuM) coiniti^ on
uciitrly aiiti sniiirtiiiH^H ]iroviii;( fatal. In itn milder ^rudeM titu UipH of
the folds of llie colim an* cappi'd wilii a thin, }'fllow exudate. In w-
V(>n<r forms I lie colnii is riimiMouHly eiilar;(edf tlie walln lire tlii('ketie<l,
slilT, and iiililtratcd, and llic iiiucoHa, from the ilro-cuM.'ul vulvo to thn
rectum, rejHcsciitcd hy a tou;(ii, yellowisli imiterial, iit which on M'ction
no trace <d* the ^^dandular eleuu-nlH can he Hccn. It irt an cxtenMivo
necrosis of the nnicosa. There an; cases in which thirt ne<TOHirt in hu-
piMlicial, involving oidy the upper layers of the mueouH inemhnmf; hut
in the most advanced forms ii may he, as in the deHCTiption hy Koki-
tansky, "a hlack, rotten, friahle, (diarred mass." 'I'ho ureaa of iiecroHiH
mav l)e mort^ localized, and lar;^e slou^dis are formecl which may l>C' a
half to three fourths of an inch in thii;kness and extend to the Hcrosa.
'I'here are instances in which this condition is conlined to the lower por-
tion of the lar«^e howel. A sailor fi-om the Mediterranean was admitted
to tlie Montreal (Jeneral Ilosjtital under my care with symptoms resem-
hling typlioid fever. The autopsy showed enormous sloughs in the rectum
and in the siL^moid tlexure, but scarcely any disease in the transverse or
ascending colon. In cases whicli last for many weeks the sloughs se])arate
and nuiy be thrown otT, sometimes in hirge tubular ])ieces.
{b) Seconiianj Diphtheritic Dysentery. — This occurs as a terminal
event in many acute and chronic diseases. It is not infrequent in chronic
heart affections, in Wright's disease, and in cachectic states generally. I"
acute diseases it is, as pointed out by Bristowe, most frequently associated
with })neumonia. Anatomically there maybe only a thin, superficial infil-
tration of tlie u])per layer of the mucosa in localized regions, j)articularly
along the ridges and folds of the colon, often extending into the ileum.
In severer forms the entire mucosa may be involved and necrotic, some-
times having a rough, granular appearance. In the secondary colitis of
pneumonia the exudation may be pseudo-membranous and form a firm,
thin, white pellicle which seems to lie upon, not within, the mucous mem-
brane.
Symptoms. — The clinical features of diphtheritic dysentery are very
varied. In the acute primary cases the patient from the outset is often
extremely ill, with high fever, great prostration, pain in the abdomen, and
frequent discharges. Delirium may be early and the clinical features may
closely resemble severe typhoid. I have, on more than one occasion,
known this mistake to be made. The abdomen is distended and often
tender. The discharges are frequent and diarrhoeal in character, and
tenesmus may not be a striking symptom. Blood and mucus may be
found early, but are not such constant features as in the follicular disease.
This primary form is very fatal, but the sloughs may separate and the
condition become chronic. In the secondary form there may have been
no symptoms to attract attention to the large bowel. In a majority of the
cases the patient has a diarrhoea — three, four, or more movements in the
10
136 SPECIFIC INFECTIOUS DISEASES.
day, wliich are often profuse and weakening. A little blood and mucus
may be passed at first, but they are not specially characteristic elements
in the stools.
In all forms of dysentery death usually results from asthenia. The
pulse becomes weaker and more rapid, the tongue dry, the face pinched,
the skin cool and covered with sweat, and the patient falls into a drowsy,
torpid condition. Consciousness may be retained until the last, but in
the protracted cases there is a low delirium deepening into collapse.
{d) Chronic Dysentery. — This usually succeeds an acute attack, though
the amoebic form may be subacute from the outset and not present an acute
period. Anatomical changes in the large intestine in chronic dysentery
are variable. There may be no ulceration, and the entire mucosa presents
a rough, irregular puckered appearance, in places slate-gray or blackish in
color. The submucosa is thickened and the muscular coats are hyper-
trophied. There may be cystic degeneration of the glandular elements,
as is beautifully figured in Woodward's volume.
Ulcers are usually present, often extensive and deeply pigmented, in
places perhaps healing. The submucous and muscular coats are thick-
ened and the calibre of the bowel may be reduced. Stricture, however, is
very rare.
The symptoms of chronic dysentery are by no means definite, and it is
not always possible to separate the cases from those of chronic diarrhoea.
Many of the characteristic symptoms of the acute disease are absent.
Tenesmus and severe griping pains rarely occur except in acute exacerba-
tions. The character of the stools varies very much. Blood and necrotic
shreddy tissue are not often found. Mucus is passed in variable amounts.
On a mixed diet the faeces are thin, often frothy, and contain particles
of food. The motions vary from four or five to twelve or more in the
twenty-four hours. There are cases in which marked constipation alter-
nates with attacks of diarrhoea, and scybala may be passed with much
mucus. In many cases the faeces have a semi-fluid consistency, and a yel-
lowish or brown color depending on the amount of bile. Fragments of
undigested food may be found, and the discharges have the character of
what is termed a lienteric diarrhoea. Indeed, variations in the bile and
in the food give at once corresponding variations in the character of the
stools. In chronic dysentery recurrences are common in which blood and
mucus again appear in the stools, accompanied perhaps by pus. Flatu-
lence is in some cases distressing, and there is always more or less ten-
derness along the course of the colon. The appetite is capricious, the
digestion disordered, and unless the patient is on a strictly regulated diet
the number of stools is greatly increased. The tongue is not often furred ;
it is more commonly red, glazed, and beefy, and becomes dry and cracked
toward the end in protracted cases. There is always anaemia and the
emaciation may be extreme ; with the exception of gastric cancer, we
rarely see such ghastly faces as in patients with prolonged dysentery.
DYSKNTKUY. 137
Tlu) (•(miplifiiliiHiM aii? llmso ulrrjuly nffncii in in iluj ucuUj form. 'I'lio
^'ri'utt'r »h"i)ility rnidcrH tlio juitinit morn liiiblu to tim iiit«rcurront af-
foctioiiH, Hurh as inii-iiiMnniii iiihI liiluTcJuloHiH. I'lLXTutioii of the cornea
WUH frr<|iuiillv iinird (lunii;^ tho civil war.
Complications and SoqueloB.—A lo<al iHritmniiH may iirim; by
extension, ni- a dilVii.so mllarnmal loM may follow juTfonilioM, which is
usiiiilly faial. When this occurs ahoiiL llic ca'cal rc^'ion, iuTily|)hlitis ro-
Hults; wlu'ii h)\v (h>\vii in thc^ rectum, periproctitis. In one hiimlred awl
ei«(ht autopsies coHectet I l.y W ixiilwanl perforation oircurred in eleven. liy
far the most serious comj)lication is abscess of tlui liv«'r, which occuth fre-
(juently in the tropics and is not very uncommon in this country. It wan
not, liowcvcr. a friMjucnt complication in dysentery during' the (Mvil war.
In this latitude it is certaiidy not uncommon, as wo have had live casen,
witiiin two years, in the .loims Hopkins Hospital. It usually comes on
insidiously Tlie symi)t()ms will be discussed in connection with hepatic
abscess.
It is stated tluit malaria is a complication, but with one exception tho
cases which I have seen w ith intermittent pyrexia were invariably associ-
ated with su})puration. in extensive epidemics, however, ^\ oodward states
that cases of ordinary dysentery occur associated with all the phenomena
of malaria. With reference to typhoid fever, as a complication, this au-
thor mentions that the combination was exceedingly frequent during the
civil war, and characteristic lesions of both diseases coexisted. In civil
practice it must be extremely rare
Sydenham noted tliat dysentery w^as sometimes associated with rheu-
matic pains, and in certain epidemics joint swellings have been especially
prevalent. They are probably not of the nature of true rheumatism, but
are rather analogons to gonorrlueal arthritis. In severe, protracted cases
there may be pleurisy, pericarditis, endocarditis, and occasionally pynemic
manifestations, among which may be mentioned pylephlebitis. Chronic
Bright's disease is also an occasional sequel. In protracted cases there
may be an anannic a?dema. An interesting sequel of dysentery is paraly-
sis. Woodward reports eight cases. Weir Mitchell mentions it as not
uncommon, occurring chiefly in the form of paraplegia. As in other acute
fevers, this is due to a neuritis.* Intestinal stricture is a rare sequence —
so rare that no case was reported at the Surgeon-GeneraFs oflRce during
the war. Among the sequelae of chronic dysentery, in persons who have
recovered a certain measure of health, may be mentioned persistent dys-
pepsia and irritability of the bowels.
Diagnosis. — The recognition of the acute follicular form is easy;
the frequency of the passages, the presence of blood and mucus, and the
tenesmus forming a very characteristic picture. Local affections of the
rectum, particularly syphilis and epithelioma, may produce tenesmus with
* Pugibet, Revue de Medecine, February, 1888.
13S SPECIFIC INFECTIOUS DISEASES.
the passage of mucoid and bloody stools. The acute diphtheritic form,
coming on with great intensity and with severe constitutional disturb-
ances, is not infrequently mistaken for typhoid fever, to which indeed in
many cases the resemblance is extremely close. The higher grade of
fever, the more pronounced intestinal symptoms, the presence, particularly
in the early stage, of a small amount of blood in the stools, the absence of
enlargement of the spleen and the rose rash should lead to a correct diag-
nosis. In the amoebic form the diagnosis can readily be made by ex-
amination of the stools. A characteristic feature of these cases is their
irregular, chronic course. A patient may be about and in fairly good
condition, with well-formed stools and very slight intestinal disturbance,
in whose faeces the amoebae may still be discovered, and in whom the
disease is at any time likely to recur with intensity. In some cases, com-
plicated by abscess of the liver and lung discharging through a bronchus,
the diagnosis may rest on the detection of amoebae in the sputa, when they
cannot be found in the stools owing to the latency of the intestinal dis-
turbance. Three such cases occurred in my wards in 1890.*
Treatment. — Flint has shown that sporadic dysentery is, in its
slighter grades at least, a self-limited disease, which runs its course in
eight or nine days. Reading a report of his cases, one is struck, however,
with their comparative mildness.
The enormous surface involved, amounting to many square feet, the con-
stant presence of irritating particles of food, and the impossibility of get-
ting absolute rest, are conditions which render the treatment of dysentery
peculiarly difficult. Moreover, in the severer cases, when necrosis of the
mucosa has occurred, ulceration necessarily follows, and cannot in any way
be obviated. When a case is seen early, particularly if there has been con-
stipation, a saline purge should be given. The free watery evacuations
produced by a dose of salts cleanse the large bowel with the least possible
irritation, and if necessary, in the course of the disease, particularly if
scybala are present, the dose may be repeated. Purgatives are, as a rule,
objectionable, and the profession has largely given up their use. Of medi-
cines given by the mouth which are supposed to have a direct effect upon
the disease, ipecacuanha still maintains its reputation in the tropics. It
did not, however, prove satisfactory during the civil war ; nor can I say
that in cases of sporadic dysentery I have ever seen the marked effect
described by the Anglo-Indian surgeons. The usual method of adminis-
tration is to give a preliminary dose of opium, in the form of laudanum or
morphia, and half an hour after from twenty to sixty grains of ipecacuanha.
If rejected by vomiting, the dose is repeated in a few hours.
Minute doses of corrosive sublimate, one hundredth of a grain every
two hours, are warmly recommended by Ringer. Large doses of bismuth,
half a drachm to a drachm every two hours, so that the patient may take
* For details see monograph of Councilman and Lafleur.
I»VSKN'ri:i(V. ];{«!
frniii tut l\n i(t liriirii ( i iiicliiiiH ill 11 dity, liuvp ill iiiiiny OMM had u Im'ih*-
liiMiil (^iTcct. 'In tin ^iun\ ii iiiiisi !)(• ^Ivrii ill turpi iIomom, iiH nT'oniineiKlird
liy MoMiirrct, wlio ^'uvd us lii^di uh Hfvoiiiy ^^iiirniiirH h day. It cfrtainly ii
iiinrc iiHcriil in till' clirniiic lluiii the lU'iito cuMrH. It iri iN'Ht ^ivcn aloiw.
()|iitiiii is all invuliiiil)l(' rciiuMly for the rrlirf of tli<i pain and to (|itict tho
peristalsis, it should In* givun uh morphia, hypo<lcriiii(.ally, iMM;ording to
I he lUM'ds of I ho VAiHV.
The tiratmt'tit of liysciitcrv l»y topical appliratioriH Ih by far tho moMt
rational plan. A Hurions obHUicio, liowovcr, in tin; acut<' ciiki'm, in tho ex-
tn'iiH^ irritahility of tho roctinn and tlm tiTU'sniiiH which follows any
atlcnipt to iiriL^at*' tho (rohni. A preliminary cocaim? Hiijipository or the
injection of a small (piantity of tlu^ f(Mir-por-(;ent Holution will HometimcH
rolievo this, and then wilh a l<>ii;^' tiihc tho Holution can ho allowed to How
in slowly. Tho patient should bo in tlu! dorsal jiosition with a pillow
under the hips, so as to ^vi tho otToctt of gravitation. Water at the tem-
perature of 100° is very soothin<^, but the irritability of the bowel is such
that lar<^o quantities can rarely bo rotainod for any time. Wlien th(? acute
symptoms subside, tbo injections are better borne. Various astringents
may be used — alum, acetate of lead, sulphate of zinc and copper, and
nitrate of silver. Of these remedies the nitrate of silver is the best,
though I think not in very acute cases. In the chronic form it is per-
haps tho most satisfactory method of treatment which we have. It is
useless to give it in tho small injections of two or three ounces with one
to two grains of the salt to the ounce. It must be a large irrigating in-
jection, which will reach all j)arts of the colon. This plan was introduced
by Hare, of Edinburgh, and is highly recommended by Stephen Mtic-
Kenzie and II. C. Wood. The solution must be fairly strong, twentv
to thirty grains to the pint, and if possible from three to six pints of
tluid must be injected. To begin with it is well to use not more than a
drachm to the two pints or two and a half pints, and to let the warm fluid
run in slowly through a tube passed far into the bowel. It is at times
intensely painful and is rejected at once. In the cases of amoebic dysen-
tery we have been using at the Johns Hopkins Hospital with great benefit
warm injections of quinine in strength of 1 to 5,000, 1 to '^,500, and 1 to
1,000. The amwbie are rapidly destroyed by it. These large injections
are not without a certain degree of danger. Brayton Ball reports the
case of a child in whom general peritonitis followed the injections. I
have never seen any ill effects, even with the very large amounts. When
there is not much tenesmus, a small injection of thin starch with half a
drachm to a drachm of laudanum gives great relief, but for the tormina
and tenesmus, the two most distressing symptoms, a hypodermic of
morphia is the only satisfactory remedy. Local applications to the
abdomen, in the form of light poultices or turpentine stupes, are very
grateful.
The diet in acute cases must be restricted to milk, whev, and broths,
140 SPECIFIC INFECTIOUS DISEASES.
and during convalescence the greatest care must be taken to provide only
the most digestible articles of food. In chronic dysentery, diet is perhaps
the most important element in the treatment. The number of stools can
frequently be reduced from ten or twelve in the day to two or three, by
placing the patient in bed and restricting the diet. Many cases do well
on milk alone, but the stools should be carefully watched and the amount
limited to that which can be digested. If curds appear, or if much oily
matter is seen on microscopical examination, it is best to reduce the
amount of milk and to supplement it with beef-juice or, better still, egg-
albumen The large doses of bismuth seem specially suitable in the
chronic cases, and the injections of nitrate of silver, in the way already
mentioned, should always be given a trial.
XXI. MALARIAL FEVER.
Definition. — An infectious disease characterized by : {a) paroxysms of
intermittent fever of quotidian, tertian, or quartan type ; (^) a continued
fever with marked remissions ; (6') certain pernicious, rapidly fatal forms ;
and (d) a chronic cachexia, with anaemia and an enlarged spleen.
With the disease are invariably associated the hsematozoa described by
Laveran.
Etiology. — (1) Geographical Distribution.— In Europe, southern Rus-
sia and certain parts of Italy are now the chief seats of the disease. It
is not widely prevalent in Germany, France, or England, and the foci of
epidemics are becoming yearly more restricted. In America it is now
rare on the Atlantic coast above the latitude of Philadelphia. From New
England, where it once prevailed extensively, it has gradually disappeared,
but there has of late years been a slight return in some places. In the city
of New York genuine malaria is rare except as an imported disease. In
Philadelphia and along the valleys of the Delaware and Schuylkill Rivers,
formerly hot-beds of malaria, the disease has become much restricted.
Except in the low-lying southern portions of the city it rarely devel-
ops, and the majority of cases admitted into hospital are of the poorer
class, who have returned from picking cranberries and peaches in Dela-
ware and New Jersey. In Baltimore a few cases develop in the autumn,
but a majority of the patients seeking relief are from the outlying dis-
tricts and one or two of the inlets of Chesapeake Bay. Though prevalent
in certain regions on this bay, the disease is yearly becoming less wide-
spread and less severe. In the Southern States there are on the seaboard
many isolated regions in which malaria prevails ; but here, too, there has
everywhere been a marked diminution in the prevalence and intensity of
the disease. W. W. Johnston states that in the Gulf district there are
places in which the disease is increasing. The percentage of cases admit-
ted to the Marine Hospital Service in 1876 was 18*4, and JJ3-4 in 1887.
MAI.AKIAL FKVKIt. 1 \\
Hilt tliis iiiiiv 1)1^ <liH< Id tlir <li\i ln|iin('iit (if tlio Hliippiii;; triulo uml to tln)
^n*Htrr miiiiiImi- (»f sailoiM who curry thr infcclioii from tliu Wviit Indiiin
|)orU, iiiid tiiosd of M(«xi<'o uihI ('nitriil Aiitcricii.
Ill IIk^ interior of liOiiiMiiitiu, MisHisHippi, ArkariKUH, and Trx.M tiiaj.ui;i
is riidciiiic, and tlm HevcM'n typcH jiru not infnMpu-nt. At irrcgulur |>cTio4iii
cpidcniicM of I lie nioHt Hcvrn^ forniH o<M'ur.
In (lie Wcslcrn and Noil liwr.^h-in Stutcrt rnalariH ia almoHt unknown.
It Ih rar(^ on the racilic coast. In tlic rc^^ion of the (ircut LukcH inuluriu
prevails only in Ihr liukc llric and Lake St. Clair rc/^ioiiH. It hax jirac-
tically disappeared rr«»ni l^ake ( hitario, wliercaH in the upper Huron and
Laki' Superior hasins it is unknown. Tiii! St. Lawrence Kiver re;,'ion re-
mains free from the disease. In Montreal a patient wilh malaria lb iuvuri-
ahly (piestioned as to Ids latest rosidenco.
(2) Tolliiric Conditions. The imjiortanco of tho state of the soil in tlio
etiology of malaria is univi-rsally reco^iuzed. It is seen ])articularly in
low, marshy rei^^ions which hav(i an abundant ve<,'etahle ^'rowtlj. Kstu-
ariivs, badly drained, low-lyini^ distrii^ts, tho course of old river-beds, trac't^
of land whicdi are ricdi in veiretable nuitter, and j»articularly districts such
as the Koman Campa^na, wliich have been allowwl to fall out of cultiva-
tion, are favorite localities for tho development of the malarial poison.
These conditions are most frecpiently found, of course, in tropical and
subtropical rei:!;ions, but nothin<i^ can be truer than the fiivt that reeking
marshes of the most i)estilcnt apj)earance may bo entirely devoid of the
poison, and the disapj)earanco of the disease from a locality is not neces-
sarily associated with any nuiterial improvement in the condition of the
marshes or of the soil. Thus, in New England and in parts of western
Canada, in which malaria formerly was very prevalent, the increased salu-
brity is usually attrilnited to the clearing of the forests and the better
drainage of the ground ; but these improvements alone can scarcely ex-
plain the disappearance, since in many districts there are marshy tracts
and low-lying lands in every respect like those in which, even at the same
latitude, the disease still prevails. Compare, for example, a swampy tract
on the northern shore of Lake Erie and a similar tract on the southern
shore of Lake Ontario ; the flora and fauna of the two districts are prac-
tically identical, but in the former the conditions under which the mala-
rial virus develops still exist, whereas in the latter they have gradually
disappeared. In short, it is impossible to ascertain from the nature of
the soil and climate in any given place whether it is malarial or not. In
the absence of accurate knowledge as to the habitat of the ha?matozoa, the
only means of deciding this point is by noticing the effect of residence in
such a place on the human subject, preferably one of the Caucasian race.
(3) Season. — Even in the tropics, where malaria constantly prevails,
there are mininuil and maximal periods ; the former corresponding to the
summer and winter, the latter to the spring and autumn months. In
temperate regions, like the central Atlantic States, there are only a few
U2 SPECIFIC INFECTIOUS DISEASES.
cases in tlie spring, nsujilly in tlie month of May, and a large number of
cases in September and October, and sometimes in November. In tlie
tropics, too, the cases are most numerons in the autumn months.
(4) Meteorological Conditions. — (a) Heat. — A tolerably high tempera-
ture is one of the essential conditions for the development of the virus.
It is more prevalent after prolonged hot summers.
(h) Moisture. — In the tropics the malarial fevers are most prevalent in
the rainy seasons. In the temperate climates the relation between the
rainfall and malaria is not so clear, and cases are more numerous after a
dry summer ; but if either heat or moisture is excessive, the development
of the virus is checked for a time.
(c) Winds. — Many facts are on record which seem to indicate that the
poison may be carried to some distance by wdnds. The planting of trees
has been held to interfere with the transmission by prevailing winds.
Possibly, however, the quickly growing trees, such as the Eucalyptus globu-
lus.) have acted more beneficially by drying the soil.
(5) Specific Gravity. — That the distribution of the poison of malaria
is influenced by gravity has long been conceded. Persons dwelling in the
upper stories, or in buildings elevated some distance above the ground,
are exempt in a marked degree.
The Specific Germ. — As Hirsch correctly remarks, the late J. K. Mitch-
ell " was the first to approach in a scientific spirit the nature of infec-
tive disease and particularly in malarial fever." Many attempts were
made to discover a constant and characteristic organism. Klebs and
Tommasi-Crudeli in 1879 announced the discovery of a bacillus 7nalarim,
but their observations have not been confirmed. In 1880 Laveran, a
French army surgeon, now professor at the Medical School at Val de
Grace, announced the discovery of a parasite in the blood of patients at-
tacked by malarial fever. During the next three years he published nine
additional communications, but for a time these observations attracted
little attention. The Italian observers Marchiafava, Celli, and Golgi
corroborated Laveran's statements. Councilman carefully studied the
question in this country, and Laveran's statements were confirmed by my-
self in Philadelphia, by Walter James in Xew York, and more recently
by Dock in Galveston. In India, Vandyke Carter has published an elab-
orate monograph on the parasites. In France, Germany, and England,
owing in great part to the absence of cases of malaria, the value of Lave-
ran's observations has been overlooked, but recently the confirmation has
been published from many of the German clinics. So far as I know, not
a single observer, who has had the necessary training and the material at
his command, has failed to demonstrate the existence of these parasites.
The bodies which have been found invariably associated with all forms
of malarial fevers, belong to the protozoa and to a group of organisms
known as the hcBmatozoa, the precise affinities of which have not yet been
definitely determined. In some respects they closely resemble the monads,
MALAiciAL ri:vi:it. 1 1:»
ill (illicrM llm Hpont/nii. I'liruHilrM of the ri(| Itlooil-cnrpiiHcli'H liavo IxTn
mot will) iiliiiii(liiiit Iv ill tilt* Mood of linh, hirtlcH, iiikI iiiaiiy HiNurii^M of
l)inlM. One of thd Ix'Ht aii*i iiinHt readily Htiidicd cxainpN'H jh i\w llrrpy-
niilinnt I'diKU'it 111^ \i vi)\\\\\ui\\ \niY\i^\\v \\\ tin* n-d Mood-rorpiiHrli'M of llii*
fn»;^^* 111 lln' Mood of palinitH with malarial frvrrH llir followiiij; fonriH
may b(^ mccii : (1) an iiii|>i;^'im"iit«'d hyalirii' body within tin; hmI IdoiHl-cror-
])iiHcl('M wliicli displayn actisr mo\riiitiitH ; (*i) a jn^^'mi'iitcd arn(j'boi<l btnly
williiii (he fed Mood corpuscdt's, wiiicli, iiiidcr ccrhiin cinMiriiHtuficeH, may
iiKMTase ill sizo and form (ii) a sc^^mcnt iii;^ Ixxly, in which tho proto-
plasm divid(>s into a variahlc luimhcr of ddiiiitc HMiall HplwrcM ; (1) cn-.s-
(•(Milic bodies, (he so-ealle(l rrrscnils^ which develop within tlur blood-cor-
pusclos and form (liaractiM'istic, and dislinctivo KtructuroH; (ri) Jla^cllat<3
ort^anisms, whicli may bo soon to develop from the intercellular j)i;,'ment-
od forms, or from ovoid bodies which are altered creH(;eiits ; (<») free Ha^'clla.
To the anueboid from within tlu^ red blood-corpuscles Marchiafava ami
(■elli p^ave the name jt/dsntofiimn mahtriiP. 1'ho following statements nuiy
be made with reference to these bodies :
Tho hiijjhest livini^ authorities on j)rotozoa, such as lUitschli, of Heidel-
berg, aeknowledge that they are truly parasitic; organisms. 'J'he testimony
is now unanimous in b' ranee, India, America, Italy, and (Jermany that these
bodies arc always present in the malarial fevers. Tiiere is no evidence to
show that they are ever present in any other disease. I can speak on this
l)oint with some eonlidence, having for years been in the habit of making
blood examinations.
The rehition of the parasites to tlie symptoms of tlie disease has been
worked out in part by (lolgi, wlio has shown that corresponding to the
paroxysm there is a })rocess of segmentation.
The rehition of the dilTerent phases of growtli to the varieties of ma-
hirial fever has not yet been tliorouglily established, but the following
points may be referred to : The typical intermittents are associated with
large forms of the parasites, of which several varieties have been described.
Golgi has described two distinct forms which he considers the causes of
tertian and quartan fevers, and makes all other types depend on combina-
tions of these. Tliis probably holds good for a large proportion of inter-
mittents. With the remittents, Marchiafava and Celli have described a
distinct species, and look upon the crescents as representing a phase in its
development. The pernicious malarial fevers are also associated with this
variety, which the Italian observers call the " small plasmodium." The
crescents may occur also in acute cases, but are most constant in malarial
cachexia. The flagellate bodies do not appear to have any definite relation
to the different forms of the disease.
The general symptoms and the morbid anatomy of malaria are in har-
* For an excellent account of these hcTmatozoa and their development, see Celli, in
Fortschritte der Medicin, 1S91.
14J: SPECIFIC INFECTIOUS DISEASES.
mony Avith the changes which this parasite induces. The destruction of
the red blood-corpuscles by it can be traced in all stages. The presence
of the pigment in the blood and the viscera, so characteristic of malaria,
results from the transformation of the haemoglobin by the plasmodia.
The anaemia is a direct consequence of the wide-spread destruction of the
corpuscles by the parasites. The constancy of their presence, the fact of
their causing rapid destruction of the red blood-corpuscles, and the
remarkable coincidence of their disappearance contemporaneously with
the symptoms on the administration of quinine, are points strongly in
favor of their etiological relation with the disease. There are still many
gaps in our knowledge. We do not know how the parasite enters, or
how or in what form it leaves the body ; how and where it is propagated ;
under what outside conditions it develops, whether free or in some aquatic
plant or animal. No record of its successful cultivation has been pub-
lished.
Meantime, awaiting further knowledge, advantage may be taken of its
constant presence in malaria. This alone, without reference to the true
nature of the organism, is a fact of the highest importance. To be able,
everywhere and undei* all circumstances, to differentiate between malaria
and other forms of fever is one of the most important advances which
has been made of late years in practical medicine, one which will revolu-
tionize the study of fevers in tropical and subtropical countries, and
should, within a short time, bring some order out of the chaos which at
present exists regarding the different forms which there prevail.*
Morbid Anatomy. — The changes result from the disintegration of
the red blood-corpuscles, accumulation of the pigment thereby formed, and
possibly the influence of toxic materials produced by the parasite. Cases
of simple malarial infection, the ague, are rarely fatal, and our knowledge
of the morbid anatomy of the disease is drawn from the pernicious mala-
ria or the chronic cachexia. Rupture of the enlarged spleen may occur
spontaneously, but more commonly from trauma. A case of the kind was
admitted under my colleague, Ilalsted, in June, 1889, and Dock has re-
cently reported two cases.
(1) Pernicious Malaria. — The condition depends apon the duration
of the infection and upon whether the patient has had previous attacks.
The blood is hydraemic and the serum may even be tinged with haemo-
globin. The red blood-corpuscles present the endoglobular forms of the
parasite and are in all stages of destruction. The spleen is enlarged,
often only moderately ; thus, of two fatal cases recently in my wards the
spleens measured 13 x 8 ctm. and 14 x 8 ctm. respectively. If a fresh
* One rises from the perusal of the recent Traite des Maladies des Pays Chaiids, by
Kelsch and Kienor, with a feeling that the key to many of the complex problems there
discussed and a totally difTerent conception of many of the features of malaria would
have been obtained had they studied the disease from the standpoint of their country-
man Laveran.
.M.\L.\Ki.\L i"i:vi:it. 145
iiifcctioM, (ill' s|ilr<'ii in iiHimlly v(>ry Hoft, uiid i\w )>tilp luke-roIorHl uimI
tiirl)i«l. Ill ca <s nf iiitiMirio rciiifiM'tion i\w Hplc(Mi riiuy Ih* fiilur^'cd uiid
tinii. 'I'lir aiiiniiiit of ))i;(iii<>nt in ilw HpliHMi (?lcriicntM in enormotiMly
iitcrnisctl. 'llw liver in HWolIni and tiirhid. In very wwie cumcii th<Tf in
not iKM'cssMiily any iiiurroHtMipic pi^^'inrnhitioii, ihoii^di inicrowrrjpic-ally
tlio cjipillarics may Ix* stulTcd willi (Ir^'rnrnitiii^ n-d liloiMl-corpiiHilrn
d(H»ply pi;(m('iit('(l. I'rrivuscnlar (portal) infiltration lian In^en found in u
very acute cas(! in a youn^ num (l)()<*k). The hrain usually hIjowh intor-
estin^ chan^^cM In sevens i'ascrt of Honin duration the tiHttuo in Htaincd,
Honu'tiini's chocolatc-colorrd. In mild caHCH tho dincoloration in pn*wnt,
hut loss marked. The hlood-vessels, especially the arterioles and capil-
laries, contain lar<^e numhers of parasites, with j)artial or total destruction
of rod hlood-corpuscles, and pi^^nnented leucocytes. Occlusions of arterioles
hy means of i)arasites are often seen. Aiueniiu and o'deniu are commoner
than conm'stion. The kidneys show analogous conditions.
('i) Mihirial Cachexia. — A ])a(ient. the suhject of chronic paludism,
usually dies of aniemia or of haMnorrhai^o associated with it. The most
eharactcristie cases of the kind which have come under my observation
have been in the workmen returning from tho Panama Canal, victims of
tho so-called C'hagros fever
Tho anannia is profound, particularly if tlie patient has died of fever.
Tho spleen is greatly enlarged, and may woigli from seven to ten pounds.
If tho disease lias ]iorsisted for any length of time, it is firm and resists
cutting. Tiio capsule is thickened, tho parenchyma brownish or yel-
lowish-brown, with areas of pigmentation, or in very protracted cases
it is extremely molanosod, particularly in the traboculae and about the
vessels.
The liver may be greatly enlarged ; but, as a rule, the increase in size
is moderate in proportion to that of the spleen. It may present to the
naked eye a grayish-brown or slate color due to the larsre amount of piir-
mont. In the portal canals and beneath the capsule the connective
tissue is impregnated with melanin. Varying with the duration of the
disease, the shade of color of the liver ranges from a light gray to a deep
slate-gray tint. The texture is firm, but there is not necessarily any great
increase in the connective tissue. Histologically, the pigment is seen in
the Kupffer's colls and the perivascular tissue.
The kidneys may be enlarged and present a grayish-red color, or areas
of pigmentation may be seen. The pigment may be diffusely scattered
and particularly marked about the blood-vessels and the Malpighian
bodies, or it is often abundant in the cells of the convoluted and collecting
tubules. The peritona?um is usually of a deep slate-color. The mucous
membrane of the stomach and intestines may have the same hue, due to
the pigment in and about the blood-vessels. In some cases this is confined
to the lymph nodules of Fever's patches, causing the shaven-beard appear-
ance.
146 SPECIFIC INFECTIOUS DISEASES.
(3) The Accidental and Late Lesions of Malarial Fever.
(a) The Liver. — Paludal hepatitis plays a very important role in the
history of malaria, as described by French writers. Kelsch and Kiener
devote over sixty pages to a description of the various forms, parenchym-
atous and interstitial, describing under the latter three different varie-
ties. The perusal of this section of their work by no means carries con-
viction that all the forms which they describe are associated definitely
with malaria. Many of the patients were the subjects of chronic alcohol-
ism, and the most important diagnostic point upon which they seem to
have placed reliance was melanosis of the spleen, sometimes with pig-
mentation of Glisson's sheath. The existence of a cirrhosis dependent
upon the irritation of large quantities of pigment in the liver is unques-
tioned, but only those cases in which the history of chronic malaria is
definite, and in which the melanosis of both liver and spleen coexist,
should be regarded as of paludal origin. The affection in this country is
of extraordinary rarity. In the post-mortem room of the Philadelphia
Hospital I have frequently seen, in subjects in whom the spleen was
deeply pigmented, the portal sheaths of the liver stained, and a slight
increase in the connective tissue ; but it is begging the question to say
that in such patients, who have almost certainly been habitual consumers
of bad whisky, the condition of the liver was due to malaria. No instance
of malarial cirrhosis has been shown at the Philadelphia Pathological
Society since its foundation. Welch tells me he knows of but one speci-
men which has been shown in New York, and that was from an Al-
gerian.
{b) Pneumonia is believed by many authors to be common in malaria,
and even to depend directly upon the malarial poison, occurring either in
the acute or in the chronic forms of the disease. I have no personal
knowledge of such a special pneumonia It certainly does not occur in
the intermittent or remittent fevers which prevail in Philadelphia and
Baltimore. The question was formerly warmly discussed in this country,
and I may refer to the attempt on the part of Manson to distinguish spe-
cial forms depending upon the malarial poison. The exhaustive and criti-
cal review of the subject by W. T. Howard, in 1859, put a check to many
of the speculations on the subject. The French authors quoted above
recognize as common in chronic paludism a form distinguished by an
irregular course, an absence of many of the characteristic symptoms, by a
rapid swelling of the liver and spleen, and a special tendency to the for-
mation of necrotic foci. On two occasions in the Philadelphia Hospital I
had an opportunity of seeing the development of pneumonia in convales-
cents from malaria — one of a quotidian, the other of a quartan type.
They developed in a ward with several other cases of pneumonia, and the
disease ran a perfectly normal course. In about four hundred cases of
malaria which have been under observation at the Johns Hopkins Hos-
pital and Dispensary bronchitis has been frequent as an early symptom,
MALARIAL IKVKIt. 147
but wu hiivo Huon no indicutioii of uiiy Hjicciul form of influrnrnation of thu
lungH.
((') yr/th riNs. —Ar.nlo itiniiiiiiimtioii of tho kidneys im ruru in tho
iiiildcr fnriMH. Alhurncn in ihv iirinn in not infnfjiicnt during' tli<; rhill,
and in tlio courso of tlio continiu'd or rcniitlcnt fexTM. Ktdricli und
Kit'iicr dcscribo m^vcnil forniM of ni'jdiritiM. No inhtun(*o of uruti? or
chronic Uri^lit'8 disuu8o resulting diructly from ])uludiHm Inw come under
my notice.
Clinical Forms of Malarial Fever.— (1) Intermittent Fever. —
Tiiis form is cluinictcrizcd by rcciinin;^' ]»:ir«txysmH of wiiat arc known a»
:ii;uc, in wiiich, us a rule, ciiill, fi-vcr, and sweat follow each other in
orderly secpicnce. 'IMie stage of inruhatiun nuiy ))e very short. Attacks
Imvo occurred within twenty-four hours after exposure. Usually the timo
of incultatioM is from seven to fourteen days. On the other hand, tlio
ague may be, as is said, " in the system," and the patient may liave u
paroxysm months after ho has removed from a malarial region, thougli I
doubt if this can be the case unless lie lias had the disease when living
there.
Description of the Pttroxysm. — The patient generally knows he is
going to have a chill a few hours before its advent by unj)leasant feelings
and uneasy sensations, sometimes by headache. The paroxysm is divided
into three stages — cold, heat, and sweating.
Cold Stuije. — The onset is indicated by a feeling of lassitude and a
desire to yawn and stretch, by headache, uneasy sensations in the epigas-
trium, sometimes by nausea and vomiting. Even before the chill begins
the thermometer indicates slight rise in temperature. Gradually the pa-
tient begins to shiver, the face looks cold, and in the fully developed rigor
the whole body shakos, flie teeth chatter, and the movements may often be
violent enough to shake the bed. Xot only does the patient look cold and
blue, but a surface thermometer will indicate a reduction of the skin tem-
perature. On the other hand, the axillary or rectal temperature may,
during the chill, be greatly increased, and, as shown in the chart, the
fever may rise during the chill to 105° or 106°. Of symptoms associated
with the chill, nausea and vomiting are common. There may be intense
headache. The pulse is quick, small, and hard. The urine is increased
in quantity. The chill lasts for a variable time, from ten or twelve
minutes to an hour, or even longer.
The hot stage is ushered in by transient flushes of heat ; gradually the
coldness of the surface disappears and the skin becomes intensely hot.
The contrast in the patient's appearance is striking : the face is flushed,
the hands are congested, the skin reddened, the pulse is full and bound-
ing, the heart's action is forcible, and the patient may complain of a
throbbing headache. The rectal temperature may not increase much dur-
ing this stage ; in fact, by the termination of the chill the fever may have
reached its maximum. The duration of the hot stage varies from half an
148
SPECIFIC INFECTIOUS DISEASES.
1
SS838SSSS
c» O c»
MAI.AKI \l, I'KVr.It.
141>
o
a
iij
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150 SPECIFIC INFECTIOUS DISEASES.
hour to three or four hours. The patient is intensely thirsty and drinks
eagerly of cold water.
Sweating Stage. — Beads of perspiration appear upon the face and
gradually the entire body is bathed in a copious sweat. The uncomforta-
ble feeling associated with the fever disappears, the headache is relieved,
and within an hour or two the paroxysm is over and the patient usually
sinks into a refreshing sleep. The sweating varies much. It may be
drenching in character or it may be slight.
Chart XI is a fac-simile of a ward temperature chart in a case of
tertian ague. The duration of the paroxysms on February 1st, 3d, and
5th was from twelve to sixteen hours. Quinine in two-grain doses was
given on the 5th and was sufficient to prevent the on-coming paroxysms
on the 7th, though the temperature rose to 100-5°. The small doses, how-
eyer, were not effective, and on the 9th he had a severe chill.
The total duration of the paroxysm is from twelve to fifteen hours, but
may be shorter. Variations in the paroxysm are common. Thus the pa-
tient may, instead of a chill, experience only a slight feeling of coldness.
The most common variation is the occurrence of a hot stage alone, or with
very slight sweating. During the paroxysm the spleen is enlarged and
the edge can usually be felt below the costal margin. In the interval or
intermission of the paroxysm the patient feels very well, and, unless the
disease is unusually severe, he is able to be up. Bronchitis is a common
symptom. Herpes, usually labial, is perhaps as frequently seen in ague as
in pneumonia.
Types of the Paroxysm. — The periodicity of the paroxysms is one
of the most striking features in malarial fever. They occur with reg-
ularity, either at the end of twenty-four, forty-eight, or seventy-two
hours.
Returning at the end of twenty-four hours the paroxysm is daily, hence
the name quotidian. This is by far the most frequent type in the acute
intermittent fevers in this latitude. Should two attacks occur daily,
which is very rare, it is called a double quotidian. The observations of
the Italian observers, more particularly Golgi, have enabled us to trace
certain definite cycles of evolution in the development of the malarial
parasites, and in the character of the organism in the different forms of
the disease. In the quotidian type the plasmodia are small at first and
display active movements. The parasite gradually increases in size, fills
the entire corpuscle, or at the beginning and prior to the paroxysm un-
dergoes in many of the corpuscles segmentation or sporulation.
If the paroxysm occurs at the end of forty-eight hours, it happens upon
the third day; hence the term tertian applied to this form. This is the
next most frequent form, but it is much less common than the quotidian
form. In tlie tertian type the blood-corpuscles contain small amoeboid
bodies which gradually develop, become deeply pigmented, and, accord-
ing to Golgi, the segmentation consists of from fifteen to twenty separate
l)(Mlii»H, ii;(^'n<<^'iitr(| kImhiI iIic (Tiilrul •Iiiiiip nf \t\^mvui. IltTo, Uk», th«
m^^niioMtulinii ni'i'tiiM jiiMi prinr to aixl during ilu* cliill.
OccmiiiiLr ill I Ik- (ihI <>f srvnit y-t w<» Immith tim piiroxyHm in on i)w
foiiitli <l.'i}\ lu'iicc till* iiiuiH* ijiinrhin ii^iio. 'DiiM in nirCf uml in t)io jiiutt
Huvcn years I luivc iiict with hut six or oi^'lit W('ll-iimrki*«l iimtjiiUM'H. In
this form 11m^ amn«lM»i»l ImhUcm lu'corm^ ni|»i<lly pi^Min'iitiMl, ']'Jh« movc>
nuMits all' slower. They ^now ^^radiially in th(« red hh)o<l-eorjMiHelefl, and,
aeeoi-dinu: to (iol^i, attain eoiiHidiM'alih; si/e without removing ull tho
ha'Mioi^litltin fidiii (he (•(ir|»iis('lcs. I'rior to I he (thill, se;,Miieiiti4tion of tho
hodies takes place into finni nine to twelvo dilTerent portionH.
OtluM' typi'ri, such as (piinlan or sextan, iwed not he conHidercd, as tliey
arc very rare.
Course of thr l)isr(tsp. — After a few paroxysms, or after the disoa-se him
persisted for ten days oi- two weeks, the patient may ^et well without any
special medication. In cases in whi(di we have been studying the ha.*ma-
tozoa 1 have repeatedly known tho chills to stop spontaneously. Such
cases, however, ari' very liahle to ri'currence. Persistence of the fever
leads to anaemia ami a ha'mato«,^enous jaundice, owing to the destruction
of the red blood-disks hy the parasites, ritimately the condition may be-
come chronic, and will be described under nudarial cachexia. Cases of
intermittent fever yield prom])tly and immediately to treatment by qui-
nine.
(2) Continued and Remittent Form of Malarial Fever.— Under this
head will be described that form of fever in which vI^^tc are no distinct
intermissions, but in which the temperature range is constantly above
normal, though there are marked remissions. It is not an uncommon dis-
ease in this locality. The severer forms of it prevail in the Southern
States and in tropical countries where it is known cliiefly as bilious remit-
teut feirr. The entire group of cases included under the terms remittent
fever, bilious remittent^ and t ijplio-malarial fevers requires to be studied
anew in the light of Laveran's observations.
Symptoms. — The disease may set in with a definite chill, or may be
preceded for a few days by feelings of malaise. As seen in this latitude, the
patient has either chilliness or a distinct rigor in the beginning. When
seen on the second or third day of the disease he has a flushed face and
looks ill. The tongue is furred, the pulse is full and bounding, but rarely
dicrotic. The temperature may range from 102° to 103°, or is in some
instances higher. The general appearance of the patient is strongly sug-
gestive of typhoid fever, a suggestion still further borne out by the exist-
ence of acute splenic enlargement of moderate grade. As in intermittent
fever, an initial bronchitis may be present. The course of these cases is
variable. The fever is continuous, with remissions more or less marked ;
definite paroxysms with or without chills may occur, in which the tem-
perature rises to 105° or 10G°. Intestinal symptoms are not present. A
slight ha3matogenous jaundice may develop early. Delirium, usually of a
11
152 SPECIFIC INFECTIOUS DISEASES.
mild type, may occur. The cases vary greatly in severity. In some the
fever subsides at the end of the week, and the practitioner is in doubt
whether he has had to do with a mild typhoid or a simple febricula. In
other instances the fever persists for from ten days to two weeks, there
are marked remissions, perhaps chills, with a furred tongue and low de-
lirium. Jaundice is not infrequent. These are the cases to which the
term bilious remittent and typho-malarial fevers are applied. In other
instances the symptoms become grave and assume a character of the per-
nicious type. It is this form of malarial fever about which so much con-
fusion still exists. The similarity of the cases at the outset to typhoid
fever is most striking, more particularly the appearance of the facies,
and the patient looks very ill. The cases develop, too, in the autumn,
at the very time when typhoid fever occurs. The fever yields, as a rule,
promptly to quinine, though here and there cases are met with, rarely
indeed in my experience, in which they are refractory. It is just in this
group that the observations of Laveran will be found of the greatest
value.
The diagnosis of malarial remittent fever may be definitely made by
the examination of the blood. Vandyke Carter, in his monograph, alludes
to the value of this method in the fevers of India. In many cases here we
are at first unable to distinguish between typhoid and continued malarial
fever without a blood examination. A more wide-spread use of this means
of diagnosis will enable us to bring some order out of the confusion which
exists in the classification of the fevers of the South. At present the fol-
lowing febrile affections are recognized by various physicians as occurring
in the subtropical regions of this continent : {a) Typhoid fever ; {h) typho-
malarial fever, a typhoid modified by malarial infection, or the result of a
combined infection ; [c) the malarial remittent fever ; and {d) continued
thermic fever (Guiteras). In these various forms, all of which may be
characterized by a continued pyrexia with remissions or with chills and
sweats (for we must remember that chills and sweats in typhoid fever are
by no means rare), the blood examination will enable us to discover those
which depend upon the malarial poison. In this latitude we have not
the opportunity of seeing many of the protracted and severe cases, but I
am inclined to think that future observations will show that apart from
the thermic fever there are only two forms of these continued fevers in
the South — the one due to the typhoid^ and the other to the malarial in-
fection. The typhoid fever of Philadelphia and Baltimore presents no
essential difference from the disease as it occurs in Montreal, a city prac-
tically free from malaria. Dock has shown conclusively that cases diag-
nosed in Texas as continued malarial fever were really true typhoid.
(3) Pernicious Malarial Fever. — Tliis is fortunately rare in temperate
climates, and tlie number of cjises which now occur, for example, in Phila-
dclpliia and Baltimore, is very much less than thirty or forty years ago.
Among the cases of malaria which have been under observation during
MAI.AKIAL I'KVKU. \y,i
iho pHst two vcarH tlicn^ wcn^ only two (tf tin- pmiifioim form. 'V\w f<A-
lowiii;^' arc \\\v most iiiiporturit typcH:
{tf) Thr ntnnttuse form, in which i\ piilicnt In Htruck down with Nymi>-
toMis (if the riiiiMt intiMiHo ccrchnil <LiHtiirhiinc(% fithor acuto delirium or,
riH»i-c fi-ci(iiciiil\, a lupiilly (h'vdopin^ coma. A chill rniiy or may not
precede the attack. The fever i.s UHually hi^'h, an«i the? Hkin h<»t and dry.
The unconsciou.sncsM may pcr.Mist f(»r from twelve to twenty-four hourn, or
the patient nuiy sink and die. After n-^^aining cons<inn>ncsH ii F«'C(»nd
attack may com(> on and prove fatal.
{!>) Ahjid Form.— In this, I he attack Het« in usually with pistric wymp-
toms; there are vt)mitin^, intense prostration, and feehlene.ss out of all
proportion to the local symptoms. The patient complains of feeling' cold,
ulthuu^^di there may he no actual chill. The temperature nuiy he nornuil
or oven suhnormid ; consciousness may be retainecl. The pulse is feeble
and snuill, and the respirations are increased. The urine is often dimin-
ished or even su])prcsse(l. This conditi(»n nuiy persist with slight exacer-
bations of fever for several days and the patient may die in a condition of
[)rofound asthenia. In a recent case the patient, admitted on October
10th, had been ill since the 7th, but there were no cliills. When first
seen he was })rostrated and weak, and looked as if he had been drinking,
but there was no alcoholic odor of the breath, and on learning that he had
recently come from Savannah, the blood was at once examined and large
numbers of Laveran's organisms were found, chiefly of the small intra-
corpuscular variety. The temperature was only 101°. During the next
five days the prostration, extreme depression, and vomiting continued;
the pulse ranged from 70 to 80, and the temperature, after the first day,
did not rise above 98°, but sank as low as 96°. This is essentially the
same as described as the asthenic or adynamic form of the disease.
{(•) Ilwmorrhagic Forms. — In all the severe types of malarial infec-
tion, especially if persistent, haemorrhage may occur from the mucous
membranes. An important form is the malarial hcematuria^ which in
some instances assumes a very malignant type. Paroxysms of ague may
precede the attack, but in many cases called malarial hjtmaturia there is
no febrile paroxysm. The condition is usually haemoglobinuria, though
blood-corpuscles are present also. In severe cases there is bleeding from
the mucous membranes. Jaundice is present, but to a variable extent,
and is hivmatogenous, due to the destruction of the red blood-corpuscles,
^lalarial lu>?maturia occurs in epidemic form in many regions of the
Southern States, and in some seasons proves very fatal.
Many different forms of pernicious malarial fever — diaphoretic, synco-
pal, pneumonic, pleuritic, choleraic, cardiac, gastric, and gangrenous — all
of which depend upon some special symptom, have been described.
(4) Malarial Cachexia. — The symptoms of chronic malarial poisoning
are very varied. It may follow the frequent recurrence of ordinary inter-
mittent fever, a common sequence in this country. A patient has chills
154: SPECIFIC INFECTIOUS DISEASES.
for several weeks, is improperly or imperfectly treated, and on exposure
the chills recur. This may be repeated for several months until the pa-
tient presents the two striking features of malarial cachexia — namely,
anccmia and an enlarged S2)leen. Cases developing without chills or with-
out febrile paroxysms are almost unknown in this region. They may
occur, however, in intensely malarial districts, but in such cases the pa-
tients have fever, though chills may not supervene. The most pronounced
types of malarial cachexia which we meet with here are in sailors from the
West Indies knd Central America. There is profound anaemia ; the blood
count may be as low as one million per cubic millimetre ; the skin has a
saffron-yellow or lemon tint, not often the light-yellow tint of pernicious
anaemia, but a darker, dirtier yellow. The spleen is greatly enlarged,
firm, and hard. It rarely reaches the dimensions of the large leukaemic
organ, but comes next to it in size.
The general symptoms are those of ordinary anaemia — breathlessness on
exertion, oedema of the ankles, haemorrhages, particularly into the retina,
as noted by Stephen Mackenzie. Occasionally the bleeding is severe, and
I have twice known fatal h^matemesis to occur in association with the
enlarged spleen. The fever is variable. The temperature may be low for
days, not reaching above 99'5°. In other instances there may be irreg-
ular fever, and the temperature rises gradually to 102'5° to 103°. The
cases in fact present a picture of splenic anaemia.
With careful treatment the outlook is good, and a majority of cases re-
cover. The spleen is gradually reduced in size, but it may take several
months or, indeed, in some instances, several years before the ague-cake
entirely disappears.
Among the rarer symptoms which may develop as a result of mala-
rial intoxication may be mentioned 2)arai^legia^ cases of which have
been described by Gibney, Suckling, and others. Some of the cases are
doubtful, and have been attributed to malaria simply because the paralysis
was intermittent. It is a condition of extreme rarity. No case is men-
tioned by Kelsch and Kiener. Suckling's case had had several attacks of
malaria, the last of wliich preceded by about two Aveeks the onset of the
nervous symptoms, which were headache, giddiness, loss of speech, and
paraplegia. The attack was transient, but he had a subsequent attack
which also followed an ague-fit. The patient was an old soldier who had
had syphilis, a point which somewhat complicated the case. Orchitis has
been descril}cd as developing in malaria by Charvot in Algiers and Fedcli
in Iiome.
Diagnosis. — The diagnosis of the various forms of malaria is usually
easy. The continued and remittent and certain of the pernicious cases
offer difficulties, which, however, are now greatly lessened or entirely over-
come since Laveran's researches have given us a positive diagnostic indi-
cation, ^lany forms of intermittent pyrexia are mistaken for malarial
fever, particularly the initial cliills of tuberculosis and of septic infection.
.M\i,\iti\L n:vi:it. ir^^
If the pnictilioiicr will hikr In liciiil tin* IrHKoii tliut iiii iiitc'rriiittL'nt f(\* r
wliii-h resists i|iiiiiiiii> is iinl rnuliiriul, lir will iiV(»i<l iiniiiy tTrorM in dia^-
iiomIm. Ill iIh< H(>-('iill(Mi iimskrd iiitcriiiitlciit or (iiiiiil) u^iiU| tlic fclirilo
IlUlni^(^stati()nM uro iiioro irrr^nilur mid tho Hyiii])t(>iiiH Ichh pnuioiiiicfMl ; hut
occjisioiwilly chills occur, iiiid llu) thcnipciiiiciii tcHt iiHiuilIy rcniovr-H evi-ry
doiiht ill till* dia^^niosis.
The iiiahii'ial poison in siippos<Ml to inl1iuMi(;o many ufTcctionH in a
rcinarlvaldc way, ^'ivin^ to them a paroxyHnml chanu-UT. A whole BcrieH
of iiiiiior ailiiiciils and smnc more suviTo ones, Hucii nn ncural^^'iu, are at-
trihutcd to certain occult elTccts of paludisni. 'J'ln^ nion; (dosely such
oases arc invest i^'ati>d the less delinite appears the conncidion with nnila-
ria. Practitioners in districts entirely exempt from the disease have to
deal with ailments w'hi(di present the same odd periodicity, and which the
physicians of the Atlantic coast attrilmte to a "touch of malaria."
Treatment. — We do not know as yet how the poison reaches the
system. Infection seems most liahle to occur at ni^dit. In regions in
which the disease prevails extensively the drinkin^^-water should he hoiled.
Persons ^oing to a malarial region should take ahout ten grains of qui-
nine daily. During the jiaroxysm the patient should, in the cold stage,
bo wrapped in blankets and given liot drinks. The reactionary fever is
rarely dangerous even if it reaches ahigb grade. Tlie body may, liowever,
bo sponged. Quinine should tben be ordered, so as to check the on-coming
])aroxysm. It should be given in solution. From ten to thirty grains in
divided doses through the day will almost invariably stop the next par-
oxysm. No preparatory treatment is necessary ; no other drugs need be
given. The remedy is a specific in the truest sense of the term. In not a
sino^lo instance anions: the several hundred cases of intermittent fever which
I have had under observation during the past seven years did quinine fail
to check the paroxysms. The mode of administration is of little moment,
so long as the patient gets a sufficient quantity into his system. In
solution or in capsule it is the most efficient. The pills and compressed
tablets are more uncertain, as they may not be dissolved. A question of
interest is the efficient dose of quinine necessary to cure tlie disease. I
have a number of charts showing that grain doses three times a day will,
in many cases, prevent the paroxysm, but not always with the certainty of
the larger doses. It is safer to give at least from twenty to thirty grains
daily for the first three days and then to continue the remedy in smaller
doses for two or three weeks. Other remedies in acute forms of malaria
are useless.
In the pernicious forms, and when it is desirable to get the system as
rapidly under its influence as possible, the drug should be administered
hypodermically (as the bisulphate in thirty-grain doses with five grains of
tartaric acid) every two or three hours. For the extreme restlessness in
these cases opium is indicated, and cardiac stimulants (such as alcohol
and strychnine) are necessary. If in the comatose form the internal tem-
156 SPECIFIC INFECTIOUS DISEASES.
perature is raised, the patient should be put in a bath and douched with
cold water.
For malarial anaemia, iron and arsenic are indicated.
XXII. ANTHRAX.
{Malignant Pustule ; Splenic Fever ; Charbon ; Wool-sorter's Disease.)
Definition. — An acute infectious disease caused by the bacillus an-
tliracis. It is a wide-spread affection in animals, particularly in sheep and
cattle. In man it occurs sporadically or as a result of accidental absorp-
tion of the virus.
Etiology. — The infectious agent is a non-motile, rod-shaped organ-
ism, the bacillus anthracis^ which has, by the researches of Pollender, Da-
vaine, Koch, and Pasteur, become the best known perhaps of all patho-
genic microbes. The bacillus has a length of from two to ten times the
diameter of a red blood-corpuscle ; the rods are often united. They mul-
tiply by fission with great rapidity and grow with facility on various cult-
ure media, extending into long filaments which interlace and produce a
dense mycelium. The spore formation is seen with great readiness in
these filaments. The bacilli themselves are readily destroyed, but the
spores are very resistant, and survive after prolonged immersion in a five-
per-cent solution of carbolic acid, and resist for some minutes a tempera-
ture of 212° Fahr. They are capable also of resisting gastric digestion.
Outside the body the spores are in all probability very durable.
Geographically and zoologically the disease is the most wide-spread of
all infectious disorders. It is much more prevalent in Europe and in Asia
than in America. The ravages among the herds of cattle in Russia and
Siberia, and among sheep in certain parts of Europe, are not equalled by
any other animal plague. In this country the disease is rare. So far as I
know it has never prevailed on the ranches in the Xorthwest, but cases
were not infrequent about Montreal.
A protective inoculation with a mitigated virus has been introduced by
Pasteur, and has been adopted in certain anthrax regions. Ilankin has
isolated from the cultures an albumose which renders animals immune
against the most intense virus.
In animals the disease is conveyed sometimes by direct inoculation, as
by the bites and stings of insects, by feeding on carcasses of animals which
have died of the disease, but more commonly by feeding in pastures in
which the germs have been preserved. Pasteur believes that the earth-
worm plays an important part in bringing to the surface and distributing
the bacilli whicli have been propagated in the buried carcass of an in-
fected animal. Certain fields, or even farms, may thus be infected for an
indefinite period of time. It seems probable, however, that if the carcass
ANTHRAX. 157
JH not <>|>iiu(I or the hlood H|iilt, Hj)orfri uru iiol fortiHMl in tbu huriiM]
iiiiiiiial.
AniiMJilM vary in Huscrptil)ility : l»rrl)ivoni in tho hijjflicHt (Ic^n***, IIhti
tlio oiimivoni, iiiiti luMtly tim nirnivoni. Tlir <liH«'iui«i <io<*H not o<M*iir nporj-
iiiiicously ill man, but alwuys rrHiiltn from infrrtion, rither tlinni^li tlio
Kkiii, tli(^ iiitcstincSf or in niru instunccH tlirou^^li liio liin^s. 'I'he liineiiM
is fonnd in iki-hoiih wIkihu oiuMiputioiiH ))rin^ tlicni into cont4u;t with urti-
nnils or anim.-il products, an Hta))lrnu'n, slicplierdH, tunntTH, but^dicTri, und
tiioso who work in wool and hair.
Various forms of the disease havn hccn (h'S(.Til)(Ml,and twochirf ^'rf>upi
niav ho recognized : the external anthrax, or mali;^'nant pustide, and tho
internal antlnax, of which there are pulmonary and intestinal forms.
Sy inptoiuB. ( 1 ) External Anthrax.
{(i) ,]/ii/i(/n(inf lUistulv. — The inoculation is nsually on an oTjmscd
8urfaco — tho hands, arms, or face. At tlic site of inoculation there arc,
within a few hours, itchin;^ and uneasiness. (Jradually a small j)apulo
develops, which hecc^nes vesicular. Intlammatory induration extends
around this, anil within thirty-six hours, at the site of inoculation thero
is a dark brownish eschar, at a little distance from which there may be a
series of small vesicles. Tho brawny induration may be extreme. The
anlema produces very great swelling of tho parts. The inflammation ex-
tends along the lymphatics, and the neighboring lym])h-glands are swollen
and sore. The temperature at first rises rapidly, and the febrile phenom-
ena are marked. Subsecpiently the fever falls, and in many cases becomes
subnormal. Death may take place in from three to five days. In cases
which recover the constitutional symptoms are slighter, the eschar gradu-
ally sloughs out, and the wound heals. The cases vary much in severity.
In the mildest form there may be only slight swelling. At the site of in-
oculation a papule is formed, which rapidly becomes vesicular and dries
into a scab, which separates in the course of a few days.
{h) Malignant Anthrax (Edema. — This form occurs in the eyelid, and
also in the liead, hand, and arm, and is characterized by the absence of the
papule and vesicle forms, and by the most extensive oedema, which may
follow rather than precede the constitutional symptoms. The oedema
reaches such a grade of intensity that gangrene results, and may involve a
considerable surface. The constitutional symptoms then become extremely
grave, and the cases invariably prove fatal.
A feature in both these forms of malignant pustule, to which many
writers refer, is the absence of feeling of distress or anxiety on the part of
the patient, whose mental condition may be perfectly clear. He may be
without any apprehension, even though his condition is very critical.
The diagnosis in most instances is readily made from the characters of
the lesion and the occupation of the patient. When in doubt, the exami-
nation of tlie fluid from the pustule may show the presence of the an-
thrax bacilli. Cultures should be made, or a mouse or guinea-pig inocu-
158 SPECIFIC INFECTIOUS DISEASES.
lated. It is to be remembered that the blood may not show the bacilli in
numbers until shortly before death.
(2) Internal Anthrax.
(a) Intestinal Form, Mycosis intestinalis. — In these cases the infec-
tion is through the stomach and intestines, and results from eating the
flesh or drinking the milk of diseased animals. The symptoms are those
of intense poisoning. The disease may set in with a chill, followed by
vomiting, diarrhoea, moderate fever, and pains in the legs and back. In
acute cases there are dyspnoea, cyanosis, great anxiety and restlessness,
and toward the end convulsions or spasms of the muscles. Haemorrhage
may occur from the mucous membranes. Occasionally there are small
phlegmonous areas on the skin, or petechiae develop. The spleen is en-
larged. The blood is dark and remains fluid for a long time after death.
Late in the disease the bacilli may be found in the blood.
This is one of the forms of acute poisoning which may affect many in-
dividuals together. Thus Butler and Karl Huber describe an epidemic
in which twenty-five persons were attacked after eating the flesh of an
animal which had had anthrax. Six died in from forty-eight hours to
seven days.
{jb) Wool-sorter'' s Disease. — This important form of anthrax is found
in the large establishments in which wool or hair is sorted and cleansed.
The hair and wool imported into Europe from Russia and South America
appear to have induced the largest number of cases. Many of these cases
show no external lesion. The infection has been swallowed or inhaled
with the dust. There are rarely premonitory symptoms. The patient is
seized with a chill, becomes faint and prostiated, has pains in the back
and legs, and the temperature rises to 102° to 103°. The breathing is
rapid, and he complains of much pain in the chest. There may be
a cough and signs of bronchitis. So prominent in some instances are
these bronchial symptoms that a pulmonary form of the disease has been
described. The pulse is feeble and very rapid. There may be vomiting,
and death may occur within twenty-four hours with symptoms of pro-
found collapse and prostration. Other cases are more protracted, and
there may be diarrhoea, delirium, and unconsciousness. Tlie recognition
of wool-sorter's disease as a form of anthrax is due to J. II. Bell, of Brad-
ford, England.
In certain instances these profound constitutional symptoms of internal
anthrax are associated with the external lesions of malignant pustule.
The diagnosis of internal anthrax is by no means easy, unless the
history points definitely to infection in the occupation of the individual.
In cases of doubt cultures should be made, and inoculations performed in
animals. Some of these cases may possibly be caused by organisms other
than the bacillus of anthrax (Cornil and Babes).
Treatment. — In malignant pustule the site of inoculation should be
destroyed by tlie caustic or hot iron, and powdered bichloride of mercury
ItAltlKS. I.VJ
may bo H|)i'iiiklr(l over lln" rxponiMl Miirfiuui. T\w loral (IrvcloptiH'nt of
tli«^ l)ii(ulli iilxMii (ho HiU) of inociilutioii niuy Ih* itrcvciitctl Uy tlit* Ntilx'iita-
iuM)iiM iiijoctioiiM of HoliilioMH of ('url)oli(' aciil or hiriilori^Ir of riicrctiry.
'V\w iiij(*(Mi()Ms hIioiiM I)(< iiwuli^ at varinim |i(iintH around the {MiHtuh% uiid
may !)(« n^pcatcd two or tlirn* tiiiicH a <lay. 'l\w internal treatment should
1)(^ eonlined to tli(^ adminintration of HtimiilantH and pletity of niitritioua
fond. I )jivii's-('oll(»y advises ipeeacuanlia powder in jloses of from fivu to
ten LTniins eviTv tlirer nr foiii' lioms.
In njali^'iiunt forms, particularly the intestinal (Mises, little can Ih; done.
Aclivi^ puri^iitives may l>e ;^dven at the outset, so as to remove the infect-
ing mati'rial. (Quinine in largo dosed has been recomm<-n<lcd.
XXIII. RABIES.
(/>^.s.'<(t ; Hydrophobia.)
Definition. — An acute disease of animals, dependent upon a specific
virus, and communicated by inoculation to man.
Etiology. — In man the disease is very variously distributed. In
Kussia it is conunon, in North Germany it is extremely rare, owing to the
wise provision that all dogs shall be muzzled. In England and France it
is much more common. In this country the disease is very rare. Since
18G7 I have seen but two cases.
Canines are specially liable to the disease. It is found most frequently
in the dog, the wolf, and the cat. All animals are, however, susceptible;
and it is communicable by inoculation to the ox, horse, or pig. The
disease is propagated chiefly by the dog, Avhich seems specially susceptible.
In the Western States the skunk is said to be very liable to the disease.
The nature of the poison is as yet unknown. It is contained chiefly in
the nervous system and is met with in the secretions, particularly in the
saliva.
A variable time elapses between the introduction of the virus and the
appearance of the symptoms. Ilorsley states that this depends upon the
following factors : " (a) Age. The incubation is shorter in children than
in adults. For obvious reasons the former are more frequently attacked.
(b) Part infected. The rapidity of onset of the symptoms is greatly de-
termined by the part of the body which may happen to have been bitten.
Wounds about the face and head are especially dangerous ; next in order
in degrees of mortality come bites on the hands, then injuries on the
other parts of the body. This relative order is, no doubt, greatly de-
pendent upon the fact that the face, head, and hands are usually naked,
while the other parts are clothed, (c) The extent and severity of the
wound. Puncture wounds are the most dangerous ; the lacerations are
fatal in proportion to the extent of the surface afforded for absorption of
160 SPECIFIC INFECTIOUS DISEASES.
tlie virus, (d) The animal conveying the infection. In order of decreas-
ing severity come: first, the wolf; second, the cat; third, the dog; and
fourth, other animals." Only a limited number of those bitten by rabid
dogs become affected by the disease; according to Horsley, not more than
fifteen per cent. On the other hand, the death-rate of those persons
bitten by wolves is higher, not less than forty per cent.
The incubation period in man is extremely variable. The average is
from six weeks to two months. In a few cases it has been under two
weeks. It may be prolonged to three months. It is stated that the incu-
bation may be prolonged for a year or even two years, but this has not
been definitely settled.
Symptoms. — Three stages of the disease are recognized :
(1) Premonitory stage, in which there may be irritation about the
bite, or pain or numbness. The patient is depressed and melancholy ;
and complains of headache and loss of appetite. He is very irritable and
sleepless, and has a constant sense of impending danger. There is often
greatly increased sensibility. A bright light or a loud voice is distressing.
The larynx may be injected and the first symptoms of difficulty in swal-
lowing are experienced. The voice also becomes husky. There is a
slight rise in the temperature and the pulse.
(2) Furious Stage. — This is characterized by great excitability and
restlessness, and an extreme degree of hyperaesthesia. "Any afferent
stimulant — i. e., a sound or a draught of air, or the mere association of a
verbal suggestion — will cause a violent reflex spasm. In man this symp-
tom constitutes the most distressing feature of the malady. The spasms,
which affect particularly the muscles of the larynx and mouth, are exceed-
ingly painful and are accompanied by an intense sense of dyspnoea, even
when the glottis is widely opened or tracheotomy has been performed "
(Horsley). Any attempt to take water is followed by an intensely pain-
ful spasm of the muscles of the larynx and of the elevators of the hyoid
bone. It is this which makes the patient dread the very sight of water
and gives the popular name to the disease. These spasmodic attacks may
be associated with maniacal symptoms. In the intervals between them
the patient is quiet and the mind unclouded. The temperature in this
stage is usually elevated and may reach from 100° to 103°. In some in-
stances the disease is afebrile. The patient rarely attempts to injure his
attendants, and in tlie intense spasms may be particularly anxious to
avoid hurting any one. There are, however, occasional fits of furious
mania, and the patient may, in the contractions of the muscles of the
larynx and pharynx, give utterance to odd sounds. This stage lasts from
a day and a half to three days and gradually passes into the —
(3) Paralytic Stage. — In rodents the preliminary and furious stages
are absent, as a rule, and the paralytic stage may be marked from the out-
set— the so-called dumb rabies. Tliis stage rarely lasts longer than from
six to eighteen hours. Tlie patient then becomes quiet; the spasms no
ic,\hii;>. 101
l()M^M*r (M-ciir ; tliri-(> in ^'nuliml iiiicoiiHcioiiHneHM ; tho h(Uirt*H iu:tioii liooomet
luort) iiiwi iiMiir riirrrl)l(M|, umi dtiitli otrriirM hy Hyii(!0|M).
Morbid Aniitoiny. — 'I'lio IrHiouH urn in tho ctTehro-Miniiul MynUTn.
'VUv l)l(M)(l-vt's.s(is uir idii^'cHlrd ; IIhto in |M'riviiH('iiliir oxiniution of \v\ir,o*
cylvH 'y jiiid lln'it' iwv iiiiniilo Ini'riKjnlm^rM. A«<'onlin^ to (iowlth, IIm'im)
uro part it'itlarlv iiMciisc^ in tin* iniMiiillii. The pliurvitx iri con^oMtcd, tlio
nuKMHis iiicmltiaiif of I he Hhniiatli is Iin pcriPinic, iiikI not iiifn'^jiw^ntly
oovtM'cd with a l»l(»(td slaiiird imikiih. TIh^ larynx, tnudica, iirnl !>ronrhi
hIjow acute con^^'stion. 'riicn^ urn no Hpeciul clian^cH in tin? ubdoniinul or
thoracic viscera. The iiiocidation cxpcrirncntn show that the virun in not
prt»sent. in the Hver, sph'cn, or kidneys, hut iri al)unihint in tlie Kpinul c(ird
and hrain.
Treatment. l*i(»|>h\la\is is of the p^reiitoHt imporUmco, and by a
aystoinutic nniz/lin<; of do^.s tho discaso can be, as in (ierniany, pra(rtically
eradicated.
Tiio bites sliouhl bo carefully wasluMl and thorou;;hly oauterizod with
caustic! ]M)tash or concentrated carbolic; acid. It is Ix'st to keep the wound
constantly open for at least fivo or six weeks. When once establisljed tho
disease is liopelessly incurable. No measures liavo been found of the
slii^htest avail, consequently tho treatment must be j)alliativc. The pa-
tient should be kept in a darkened room, in charge of not more than two
careful attendants. To allay the spasm, chloroform may be administered
and mor])hia i^iven ]iyi)odermieally. It is best to use these ])owerful reme-
dies from the outset, and not to temporize with cliloral, bromide of potas-
sium, and other less potent drugs. By the local application of cocaine,
the sensitiveness of the throat may be diminished sufhciently to enable
the patient to take liquid nourishment. Sometimes he can swallow read-
ily. Nutrient enemata may be administered.
Preventive Inoculation. — Pasteur has found that tlie virus, wlien propa-
gated through a series of rabbits, increases rapidly in its virulence; so that
whereas subdural inoculation from the brain of a mad dog takes from fif-
teen to twenty days to produce the disease, in successive inoculations in a
series of rabbits the incubation period is gradually reduced to seven days.
The spinal cord of these rabbits contains tlie virus in great intensity, but
when preserved in dry air the virus gradually diminishes in intensity. If
now dogs are inoculated with cords preserved for from twelve to fifteen
days, and then with cords preserved for a shorter period, i. e., with a pro-
gressively stronger virus, they gradually acquire immunity against the dis-
ease. A dog treated in this way will resist inoculation with material from
a perfectly fresh cord from a rabid rabbit, which otherwise would inevi-
tably have proved fatal. Relying upon these experiments, Pasteur began
inoculations in the human subject using, on successive days, material from
cords in which the virus was of varying degrees of intensity.
There is still much discussion as to the full value of this method,
but if the protective inoculation can be successfully performed in dogs,
162 SPECIFIC INFECTIOUS DISEASES.
there is no reason why the same should not hold good for man ; and the
figures published annually from the Pasteur Institute show that in per-
sons bitten by animals known to have been rabid, the mortality after in-
oculation is only about 0*60 per cent.
Pseudo-rabies. — This is a very interesting affection, which may
closely resemble hydrophobia, but is really nothing more than a neurotic
or hysterical manifestation. A nervous person bitten by a dog, either
rabid or supposed to be rabid, develops within a few months, or even later,
symptoms somewhat resembling the true disease. He is irritable and de-
pressed. He constantly declares his condition to be serious and that he
will inevitably become mad. He may have paroxysms in which he says he
is unable to drink, grasps at his throat, and becomes emotional. The tem-
perature is not elevated and the disease does not progress. It lasts much
longer than the true rabies, and is amenable to treatment. It is not im-
probable that a majority of the cases of alleged recovery in this disease
have been of this hysterical form. In a case which Burr reported from
my clinic a few years ago the patient had paroxysmal attacks in which he
could not swallow. He was greatly excited and alarmed at the sight of
water and was extremely emotional. The attack lasted for a couple of
weeks and yielded to treatment with powerful electrical currents.
XXIV. TETANUS.
{Lockjaw^
Definition. — An infectious malady characterized by tonic spasms of
the muscles with marked exacerbations. The virus is produced by a
bacillus which occurs in earth and sometimes in putrefying fluids and
manure.
Etiology. — It occurs as an idiopathic affection or follows trauma. It
is frequent in some localities and has prevailed extensively in epidemic
form among new-born children, when it is known as tetanus or trismus
neonatorum. It is more common in hot than in temperate climates,
and in the colored than in the Caucasian race. This is particularly
the case with tetanus following confinement and in tetanus neonato-
rum. In certain of the West India Islands more than one half of the
mortality among the negro children has been due to this cause. In a ma-
jority of the cases there is an injury which may be of the most trifling
character. It is more common after punctured and contused than after
incised wounds, and frequently follows those of the hands and feet. The
disease usually appears within two weeks of the injury. In some military
campaigns tetanus has prevailed extensively, but in others, as in the late
civil war, the cases have been comparatively few. Idiopathic tetanus is
rare in man, but it has sometimes followed exposure to cold or after sleep-
ing on the damp ground.
TKTAM.'S. 153
'V\w iiifiM'tiniiH iiiitiiro of tctiiiiiiH wiiH Hii^'^cNtcd by itri cnrlcmiic fK'fur-
rciii-c ami \'\i<\\\ I Ih> inaiiricr nf itH hrliiivior ill certain iiiHtitutidriN. V(?t*
oriiiuriiiiiM inivr U*i\^ Imcm of lliin Ix'licf, uh ciimdh un; iipt to (Mrfriir to^^i'tlicr
ill lioi'Mcs ill niM^ Htiiiilr. Ill tliu riiitcMl StiitoH iitU'iitioii Wiu4 curl)' culU'd U)
this fciilurt' l>v iIki prcvulciicj' of tlw dirtcjiHo in tin; fiwtiTii r-ml of I/Oiig
Isliiiid.
Tlio Totiiiius Haoillus. 'I'lio ()l).s(?rvationM of ItoHi'iiljach, NiroIaitT, unci
Kitusulo liuvc (IciMoiistnitrd tliut tlicru in in ronncctioii with tin; diHcuMc* a
sjKJcilic orpiiiisiii wliiiii can In; isohUi'd and cultivati-d, 'V\w l>iu'iIliiH forniH
a slondtT rod witli roiindi'd i'IkIh and may ^row into lon^ tlireadH. It in
inotilc, i^n-ows at ordinary tcmpcratiin's, and in anar-robic;. With Hinall *jiian-
titit's of tiic ciiltiirt' tlu' disi'asi; may Ik; traiiHinittiMl to animals, wlii(;li die
with symptoms of tetanus. An extruincly inturt'stini^ fact is tlio Hcpara-
tion hy liricLrcr, froiu the t-ulturos as woll as from a Hubject dead of teta-
nus, of })oisonous substances cai)abli' of produc.'in|( tlie jliseasc. Of these
})tomaines one, /<7^^;//;/, causes the characteristic symjitoins of tetanus; an-
otlior causes triMiiors, convulsions, and subse(juently ])aralysis; and a third
causes at once intense clonic and tonic spasms. Another j)oint of interest
is the fact that ])rotection in animals can ])c procured by inoculatin<^ an
animal with the blood of another which has had the disease. The organ-
ism has beiMi found in tlie earth and in j)utrefying fluids, and Nicola'ier
has caused the disease by inoculating with diflerent sorts of surface soil.
Morbid Anatomy. — No characteristic lesions have been found in
the cord or in the brain. Congestions occur in dilTerent parts, and jieri-
vascular exudations and granular changes in the nerve-cells have been
found. The condition of the wound is variable. The nerves are often
found injured, reddened, and swollen. In the tetanus neonatorum the
umbilicus may be intiamed.
Symptoms. — After an injury the disease sets in usually within ten
days. h\ Yandeirs statistics at least two fifths, and in Josej)h Jones's
four fifths, occurred before the fifteenth day. The patient complains at
first of slight stillness in the neck, or a feeling of tightness in the jaws, or
ditticulty in mastication. Occasionally chilly feelings or actual rigors may
precede these symptoms. Gradually a tonic spasm of the muscles of these
parts develops, producing the condition of trismus or lockjaw\ The eve-
brows may be raised and the angles of the mouth drawn out, causing the
so-called sardonic grin — risus sardo?iinis. In children the spasm mav be
confined to these parts. Sometimes the attack is associated with paralysis
of the facial muscles and difficulty in swallowing — the head tetanus of
Rose, which has most commonly followed injuries in the neighborhood of
the fifth nerve. Gradually the paroxysms extend and involve the muscles
of the body. Those of the back are most affected, so that during the spasm
the unfortunate victim may rest upon the head and heels, a position known
as opisthotonos. The rectus abdominalis muscle has been torn across in
the spasm. The entire trunk and limbs may be perfectly rigid — orthoto-
164 SPECIFIC INFECTIOUS DISEASES.
nos. Flexion to one side is less common — pIeurosthoto?ios ; while spasm
of the muscles of the abdomen may cause the body to be bent forward —
eynprosthotonos. In very violent attacks the thorax is compressed, the res-
pirations are rapid, and spasm of the glottis may occur, causing asphyxia.
The paroxysms last for a variable period, but even in the intervals the
relaxation is not complete. The slightest irritation is sufficient to cause
a spasm. The paroxysms are associated with agonizing pain, and the
patient may be held as in a vise, unable to utter a word. Usually he is
bathed in a profuse sweat. The temperature may remain normal through-
out, or show only a slight elevation toward the close. In other cases the
pyrexia is marked from the outset; the temperature reaches 105° or 106°,
and before death 109° or 110°. In rare instances the temperature may
reach a still higher point. Death either occurs during the paroxysm from
heart-failure or asphyxia, or is due to exhaustion.
Diagnosis. — Well-developed cases following a trauma could not be
mistaken for any other disease. The spasms are not unlike those of
strychnia-poisoning, and in the celebrated Palmer murder trial this was
the plea for the defence. The jaw-muscles, however, are never involved
early, if at all, and between the paroxysms in strychnia-poisoning there is
no rigidity. Certain cases of the so-called cephalic tetanus in which there
is difficulty of swallowing might be mistaken for hydrophobia, but in this
disease there is never the stiffness of the jaws nor paroxysms in which the
cervical and dorsal muscles are affected. In tetany the distribution of the
spasm at the extremities, the peculiar position, the greater involvement of
the hands, and the condition under which it occurs, are sufficient to make
the diagnosis clear.
Prognosis. — Two of the Hippocratic aphorisms express tersely the
general prognosis even at the present day : " The spasm supervening on a
wound is fatal," and " such persons as are seized with tetanus die within
four days, or if they pass these they recover."
The mortality in the traumatic cases is not less than eighty per cent.
(Conner) ; in the idiopathic cases it is under fifty per cent. According to
Yandell the mortality is greatest in children. Favorable indications are
— late onset of the attack, localization of the spasms to the muscles of the
neck and jaw, and an absence of fever. Most of the cases of Rose's head
tetanus, the so-called tetanus liydropliohicus^ recover.
Treatment. — The patient should be kept in a darkened room, abso-
lutely quiet, and attended by only one person. All possible sources of
irritation should be avoided. Veterinarians appreciate the importance of
this complete seclusion, and in well-equipped infirmaries there may be
seen a brick padded chamber in which these cases are treated.
When the lockjaw is extreme it may be impossible to feed the patient,
under which circumstances it is best to use rectal injections, or to feed by
a catheter passed through the nose. The spasm should be controlled by
chloroform, which may be repeatedly given at intervals. It is more satis-
svriiii.is. 105
fuclntv In kit'|> tlir |i;iiiriit t lioroii^'li 1 y iiixlcr till) inniii^nro of riiorphiu
^ivni li\ |mmI(| iiiicully. Clilonil liyiinilo, hrotniilp of |totiu4Miiirfi, ('iilulmr
Imuui, ctiniia, Imliiui liniip, lii'lladninm, iim«1 other druf^N iuivc Im'^m n^roin.
iimmhNmI, nixi iTcnvciv (K'ciiMinimlly followH tln-ir um*. Am tin* ioxw mffuiH
appnir to In* |»I(mIiic(m1 hy hucilli ut tlit* hilc of tlic lfhi(»ii, thoroiifli <\t:iUn-
iiig uiul iinUs()|iti(: trouiinunt hIiouM bu curriud uiit.
XXV. SYPHILIS.
Definition. — A spccillc disease of slow evolution, jjrojia^Mled \>y
inocMlation (actjiiired sypliilis), or l)y luTeditary truriHriiisHion (congernUil
syphilis). In the acquired fniui tiu' siie(»f inoculation becornoH the seat of
a special tissue change — prifiii/ri/ lesion. After an interval of two or three
months constitutional syniptonis devel(»p, with ulTections of the skin and
mucous nuMuhranes — scnnKlanj lesions. And, iinally, after a period of
thrc(% four, or more years, granulomatous growths develop in the viscera,
muscles, hones, or skin — tertinnj lesittns.
1. (iKNKK.VL IvII(H-()(;Y AND MoKl'.ID A.NATOMY.
The nature of thi^ virus is still douhtful. Lustgarten fouiul in the
hard chancre and in gummata a r()d-sha})ed bacillus of )J or 4 /i in length,
which he claims is specilic aiul })cculiar to the disease. This organism
closely resembles the smegnui bacillus, which is founil beneath the pre-
puce, but from its occurrence in gummatous growths it is hardly possible
that they can be identical. Further observations are required before the
question can be considered settled.
Syphilis is peculiar to man, and cannot be transmitted to the lower
animals. All arc susceptible to the contagion, and it occurs at all ages.
Modes of Infection. — (1) In a large majority of all cases the disease is
transmitted by se.rnal congress, but the designation venereal disease, lues
venerea, is not always correct, as there are many other modes of inocula-
tion.
(2) Accidental Infecfion. — In surgical and in midwifery practice, phy
sicians are not infrequently inoculated. It is surprising that infection
from these sources is not more common I have known personally of six
cases. Midwifery chancres are usually on the finders, but I have met
with one instance on the back of the hand. Lip, mouth, and tonsillar
sores result as a rule from improper practices. Wet-nurses are sometimes
infected on the nipple, and it occasionally happens that relatives of the
child are accidentally contaminated. One of the most lamentable forms
of accidental infection is the transmission of the disease in humanized
vaccine lymph. This, however, is extremely rare. The conditions under
which it occurs have been already referred to (see Vaccination).
(3) Hereditarij Transmission. — This may be, and is most common,
166 SPECIFIC INFECTIOUS DISEASES.
from (a) tlie father, the mother being healthy (sperm inheritance). It is,
unfortunately, an every-day experience to see cases of congenital syphilis
in which the infection is clearly paternal. A syphilitic father may, how-
ever, beget a healthy child, even when the disease is fresh and full-blown.
On the other hand, in very rare instances, a man may have had syphilis
when young, undergo treatment, and for years present no signs of disease,
and yet his first-born may show very characteristic lesions. Happily, in a
large majority of instances, when the treatment has been thorough, the
offspring escape. The closer the begetting to the primary sore, the greater
the chance of infection. A man with tertiary lesions may beget healthy
children. As a general rule it may be said that with judicious treatment
the transmissive power rarely exceeds three or four years.
(b) Maternal transmission (germ inheritance). It is a remarkable
and interesting fact that a woman who has borne a syphilitic child is her-
self immune, and cannot be infected, though she may present no signs of
the disease. This is known as Colles's law, and was thus stated by the
distinguished Dublin surgeon : " That a child born of a mother who is
without obvious venereal symptoms, and which, without being exposed to
any infection subsequent to its birth, shows this disease when a few weeks
old — this child will infect the most healthy nurse, whether she suckle it or
merely handle and dress it ; and yet this child is never known to infect its
own mother, even though she suckle it while it has venereal ulcers of the
lips and tongue." In a majority of these cases the mother has received a
sort of protective inoculation, without having had actual manifestations of
the disease.
A w^oman with acquired syphilis is liable to bear infected children.
The father may not be affected. In a large number of instances both
parents are diseased, the one having infected the other, in which case the
chances of fcetal infection are greatly increased.
(c) Placental transmission. The mother may be infected after con-
ception, in which case the child may be, but is not necessarily, born syph-
ilitic.
Morbid Anatomy. — The primary lesion, or chancre, shows: (a) A dif-
fuse infiltration of the connective tissue with small, round cells, (h)
Larger epithelioid cells, (c) Giant cells, (d) The Lustgarten bacilli, in
small numbers, (e) Changes in the small arteries, chiefly thickening of
the intima, and alterations in the nerve-fibres going to the part (Berkeley).
The sclerosis is due in part to this acute obliterative endarteritis. Asso-
ciated with the initial lesions are changes in the adjacent lymph-glands,
which undergo hyperplasia, and finally become indurated.
The secondary lesions of syphilis are too varied for description here.
They consist of condylomata, skin eruptions, affections of the eye, etc.
The tertiary lesions consist of circumscribed tumors known as gum-
mata, and of an arteritis, which, however, is not peculiar to the disease.
Gummata. — Syphilomata develop in the bones or periosteum — here
HYIMIIMS. 107
i\wy jut^ ciillitl iiotirs -in tin- miiHrlcrt, Mkiri, hruiii, lim;(, livrr, kuiwyn^
hojirt, U'sU'M, uikI lulroimlM. 'I'lu-y vary in nizo from HiitiiU, iiliiioHt iiiirro-
acoj)i(\ iMxlioM tolur^tN Holi«l tiimoiH fnnii tlircti to five? ccnliiiiutri^M in diurn-
etor. 'V\wy iirt< UHUully linn uihI ImnI, l)iit in th« Mkin und on i\w niiurouii
intMiihruiicH i\wy iv\u\ to l»nMik down ni|Mdly and wl<**Tut<*. On (Tomh-m«;<>
tion 11 incdiMni-Ki/.cd ^Minunii has a ^'rayisli-wliitr, linrno^'rni'ouH upin-ur-
ancc, pit'si'ntin^' in tln' ccnliv a linn, ca-^tMniM HulintainM', and at thr j>e-
ripluMV a (ranshiccnt, lil>ronH tinsur. Ofton there are ^rou]>H of three or
ninic smroiin.lcd l>y di'nse Hclerotic; tiHHue. They are unually very firm
and hard. I list()h)^n('ally, a Hinali ^Minima coiiHiHtH of a j^'ranuhition tiHHiie
c'onipost'd of rounded cells. Owin^' to inHufVicient l)lo(>(l-.snpply, coa^nda-
tion necrosis takes place in the centre with the fornjati«)n of a lihro-caseouH
material, while the j^n'owth extends at the margins with the gradual pro-
duction of lihre-cells. I'ltimately tlio central caseous part may be ab-
sorbed, and healing takes place with the development of a librous scar.
The arteritis will hi' considered in a separate section.
II. AcgriKKi* Syphilis.
Primary Stage. — This extends from the appearance of the initial sore
until the onset of the constitutional symptoms, and has a variable dura-
tion of from six to twelve weeks. The initial sore appears within a month
after inoculation, and it first shows itself as a small red papule, which
gradually enlarges and breaks in the centre, leaving a small ulcer. The
tissue about this becomes indurated so that it ultimately has a gristly, car-
tilaginous consistence — hence the name, liard or indurated chancre. The
size attained is variable, and when small the sore may be overlooked, par-
ticularly if it is just within the urethra. The glands in the lymph-district
of the chancre enlarge and become hard. Suppuration both in the initial
lesion and in the glands may occur as a secondary change. The general
condition of the patient in this stage is good. There may be no fever
and no impairment of health.
Secondary Stage. — The first constitutional symptoms are usually mani-
fested within three months of the appearance of the primary sore. They
rarely develop earlier than the sixth or later than the twelfth week. The
symptoms are : (a) Fever, slight or intense, and very variable in charac-
ter. A mild continuous pyrexia is not uncommon, the temperature not
rising above 101°. The fever may have a distinctly remittent character ;
but the most remarkable and puzzling type of syphilitic fever is the inter-
mittent, which often leads to error in diagnosis. The fever may come on
within a month after exposure and rise to 104° or 105°, with oscillations
of five or six degrees (Yeo) A remarkable case is reported by Sidney
Phillips, in which pyrexia persisted for months, with paroxysms resem-
bling in all respects tertian ague, and which resisted quinine and yielded
promptly to mercury and potassium iodide. Although usually a secondary
manifestation, the fever of s}'philis may occur late in the disease.
12
168 SPECIFIC INFECTIOUS DISEASES.
(b) Anwmia. — In nicany cases the syphilitic poison causes a pronounced
anaemia wliich gives to the face a muddy pallor, and there may even be a
light-yellow tingeing of the conjunctivae or of the skin, an haematogenous
icterus. This syphilitic cachexia may in some instances be extreme. The
red blood-corpuscles do not show any special alterations. The blood-
count may fall to three millions per cubic millimetre, or even lower, and
the haemoglobin to forty or fifty per cent (Hayem). No characteristic
organisms have been found in the blood.
{c) Cutaneous Lesions. — Skin eruptions of all forms may develop.
The earliest and most common is a rash — macular syphilide or syphilitic
roseola — which occurs on the abdomen, the chest, and on the front of the
arms. The face is often exempt. The spots, which are reddish-brown
and symmetrically arranged, persist for a week or two. Next in frequency
is 'd papular syphilide, which may form acne-like indurations about the
face and trunk, often arranged in groups. Other forms are the pustular
rash, which may so closely simulate variola that the patient may be sent
to a small-pox hospital. A squamous syphilide occurs, not unlike ordi-
nary psoriasis, except that the scales are less abundant. The rash is more
copper-colored and not specially confined to the extensor surfaces.
In the moist regions of the skin, such as the perinaeum and groins, the
axillae, between the toes, and at the angles of the mouth, the so-called
mucous patches develop, which are flat, warty outgrowths, with well-defined
margins and surfaces covered with a grayish secretion. They are among
the most distinctive lesions of syphilis.
Frequently the hair falls out (alopecia), either in patches or by a
general thinning. Occasionally the nails become affected (syphilitic
onychia).
(d) Mucous Lesio7i^. — With the fever and the roseolous rash the throat
and mouth become sore. The pharyngeal mucosa is hyperaemic, the ton-
sils are swollen and often present small, kidney-shaped ulcers with gray-
ish-white borders. Mucous patches are seen on the inner surfaces of the
cheeks and on the tongue and lips. Sometimes on the tongue there are
whitish spots (leucomata), which are seen most frequently in smokers, and
which Hutchinson regards as the joint result of syphilitic glossitis and the
irritation of hot tobacco-smoke. Hypertrophy of the papillae in various
portions of the mucous membrane produces the syphilitic warts or condy-
lomata which are most frequent about the vulva and anus.
(e) Other Lesions. — Iritis is common, and usually affects one eye be-
fore the other. It develops in from three to six months after the chancre.
There may be only slight ciliary congestion in mild cases, but in severer
forms there is great pain, and the condition is serious and demands care-
ful management. Choroiditis and retinitis are rare secondary symptoms.
Ear affections are not common in the secondary stage, but instances are
found in which sudden deafness develops, which may be due to labyrinth-
ine disease ; more commonly the impaired hearing is due to the extension
HYI'IIILIS. K'/j
of intlaiiiiiiui I'Mi frniii I Im' I luoiit (o ilir iiii<iill<> car. MpMiidyniiliH in iiri
(XUMlHioiml HCCnliduiV Irsioll.
Ttu'tiary Sta^n. N<> liiir<l jin'l fuHt line ciin U? <lniwn lM'tw<M?n the
losions of IIm' stM'diKiiiry iiml (Iioho of tho U^rliiiry )>urio4l ; fiiidf indocd, in
(<.\('(>p(i()ii!(l cuMcM, iiiiiiiifrshitiniiM whiidi liHiiidly iip|M'Hr liilr ihhv M'X in
(niMi Ix'fori' llu' primiirv hoic Ijum properly Ix-jih-d. '1'Im^ HpiM-ial alT<*(lionM
of lliiH sla^M* aro cci-tain skin erupt ions, ^niniiiatoiiH growtliH in llio mhvath^
and amyloid dcucncrat i<»iis.
((f) 'I'll*' l;il(^ sjiphilidrs show H grrater tendency to uh^eration and
destnuilion of the dccpn- layers of i\w Hkirj, ho that in healin;^ warM
are left. Tliey are also more Kcattered and seldom symmetri<al. One
of the most idiaraeteristic of tlu; tertiary syphiliden is riipia, the; dry
stratilied crusts of whidi cover an ulcer which involveH the deeper layere
of the skin and in hcahii;; h'aves a scar.
(/>) (lUinnKttit. — 'i'hesi> may develop in the nkin, Hubcutancou8 tisaue,
muscles, or internal or<;ans. 'i'he general character lias been alreiwly
described. When they develop in the skin they tend to break down and
ulcerate, leavin<2^ "K'X -"^^''t^s which heal with difliculty. In the solid
organs they undergo libroid transformation and |)roduce puckering and
deformity. On the mucous membranes tliese tertiary lesions lead to
idc(M-ation, in the iuvding of wliich cicatrices arc formed; tlius, in tlie
larynx great narrowing may result, and in the rectum ulceration with
libroid thickening and retraction may lead to stricture.
(r) Amijloid Dcf/oicrafiofi. — Syphilis plays a most important role m
tlie production of this atTection. Of 24:4: instances analyzed by Fagge,
7G had syphilis, and of these 42 had no bone lesions. It follows the
acquired form and is very common in the rectal disease in women. In
cons^enital hies amyloid degeneration is rare.
(d) Sclerosis — Syphilis is an important factor in inducing degenera-
tive changes in certain tissues. In locomotor ataxia the association be-
tween this disease and sclerosis of the posterior columns of the cord is far
too frequent to be accidental, but the precise relations cannot, with our
present knowledge, be explained. With regard to arterio-sclerosis, the part
plavfd by syphilis is unquestioned, but the nature of the connection of the
two processes remains doubtful.
III. Co^fCxENiTAL Syphilis.
With the exception of the primary sore, every feature of the acquired
disease mav be seen in the cons^enital form.
The intra-uterine conditions leading to the death of the foetus do not
here concern us. The child may be born healthy-looking, or with well-
marked evidences of the disease. In the majority of instances the former
is the case, and within the first month or two the signs of the disease
appear.
Symptoms. — (a) At Birth. — When the disease exists at birth the
170 SPECIFIC INFECTIOUS DISEASES.
child is feebly developed and wasted, and a skin eruption is usually
present, commonly in the form of bullae about the wrists and ankles, and
on the hands and feet (pemphigus neonatorum). The child snuffles, the
lips are ulcerated, the angles of the mouth fissured, and there is en-
largement of the liver and spleen. The bone symptoms may be marked,
and the epiphyses may even be separated. In such cases the children
rarely survive long.
(b) Early Mctnifestatio7is. — When born healthy the child thrives, is
fat and plump, and shows no abnormity whatever ; then from the
fourth to the eighth week, rarely later, a nasal catarrh develops, syphilitic
rhifiitis, which impedes respiration, and produces the characteristic
symptom which has given the name snuffles to the disease. The dis-
charge may be sero-purulent or bloody. The child nurses with great
difficulty. In severe cases ulceration takes place with necrosis of the
bone, leading to a depression at the root of the nose and a deformity
characteristic of congenital syphilis. This coryza may be mistaken at
first for an ordinary catarrh, but the coexistence of other manifestations
usually makes the diagnosis clear. The disease may extend into the
Eustachian tubes and middle ear and lead to deafness.
The cutaneous lesions develop with or shortly after the onset of the
snuffles. The skin often has a sallow, earthy hue. The eruptions are
first noticed about the nates. There may be an erythema or an eczematous
condition, but more commonly there are irregular reddish-brown patches
with well-defined edges. A papular syphilide in this region is by no
means uncommon. Fissures develop about the lips, either at the angles
of the mouth or in the median line. These rhagades^ as they are called,
are very characteristic. There may be marked ulceration of the muco-
cutaneous surfaces. The secretions from these mouth lesions are very
virulent, and it is from this source that the wet-nurse is usually infected.
Not only the nurse, but members of the family, may be contaminated.
There are instances in which other children have been accidentally inocu-
lated from a syphilitic infant. The hair of the head or of the eyebrows
may fall out. The syphilitic onychia is not uncommon. Enlargement of
the glands is not so frequent in the congenital as in the acquired disease.
When the cutaneous lesions are marked, the contiguous glands can usually
be felt. As pointed out by Gee, the spleen is enlarged in many cases.
The condition may persist for a long time. Enlargement of the liver,
though often present, is less significant, since in infants it may be due to
various causes. These are among the most constant symptoms of con-
genital syphilis, and usually develop between the third and twelfth
weeks. Frequently they are preceded by a period of restlessness and wake-
fulness, particularly at night. Some authors have described a peculiar
syphilitic cry, high-pitched and harsh. Among rarer manifestations are
haemorrhages — the syphilis hmmorrhagica neonatorum. The bleeding
may be subcutaneous, from the mucous surfaces, or, when early, from the
svniii.is. 171
niiil»ili«'iiM. All of Hiicli ciiscM, Imwrvrr, an- not Hypliilitic, mid tin* diHi'iutf!
iMiist ii(»t l)(M'((iiroiiii(lc(l with thn uciiU; liM'iiio^loliiiiiiriii of iifw-horn in-
fimtH, wiiicii WiiM'kcl dcHcrihcvM nn (M-ciirrin^ in i-pidi'iiiic form, uiid which
in prnhahlv an a<iilc iiifcciioUH (lis(»r<|<-i\
{<•) L(tl(' .M(inif'rstitfi(tns. — Ohildirn with (!Oii^'cnitiil HVphili^ nindy
llnivc. I'siially llicy prcHniit ii wizi'iird, wiiHtod appfuniiu;!', und u pn;-
inatnrclv a^t'd face in tlu^ cascM which recover, tin- ^'eneral nutrition
may remain ^otod and the child may show no fiirtjjer manifestjitionH of
th« (liseas(^; commonly, howc^ver, at thi^ period of necond (h'litition or at
puhcrt V the (liMeascs reappears. Althow^^di the (ddld may liave recovered
from tlu> early lesions, it does not develop like other children, (irowth is
slow, developnuMit tardy, and there are facial and cranial characterirtticH
which often render the disease recoi^ni/ahle at a glance. A youn<^' man of
nineteen or twenty may neither look older nor he more developed than a
boy of ten or twelve. Kournier describes this condition as infitntHisin.
The forehead is prominent, the fn>ntal eminences are nuirked, and the
skull may be very asymmetrical. The bri<lf]^o of the nose is depressed,
the tip retrousse. The lips are often prominent, and there are striated
lines running; from the corners of the mouth The teeth are deformecl
and may })resent appearances which Jonathan Hutchinson claims are
specitic and peculiar. 'I'he upper central incisors of the permanent set
are the teeth which give information. The specific alterations are — the
teeth are peg-shaped, stunted in lengtli and breadth, and narrower at the
cutting edge than at the root. On the anterior surface the enamel is
well formed, and not eroded or honeycombed. At the cutting edge there
is a single notch, usually shallow, sometimes deep, in which the dentine is
exposed.
Among late manifestations, particularly apt to appear about puberty,
is the interstitial keratitis^ which usually begins as a slight steaminess of
the cornea^, which present a ground-glass appearance. It affects both
eyes, though one is attacked before the other. It may persist for months,
and usually clears completely, though it may leave opacities, which pre-
vent clear vision. Iritis may also occur. Of ear affections^ apart from
those which develop as a sequence of the pharyngeal disease, a form occurs
about the time of puberty or earlier, in which deafness comes on rapidly
and persists in spite of all treatment. It is unassociated with obvious
lesions, and is probably labyrinthine in character. Bone lesions, occurring
oftenest after the sixth year, are not rare among the late manifestations of
hereditary syphilis. The tibiiv are most frequently attacked. It is really
a chronic gummatous periostitis, which gradually leads to great thicken-
ing of the bone. The nodes of congenital syphilis, which are often mis-
taken for rickets, are more commonly diffuse and affect the bones of the
upper and lower extremities. They are generally symmetrical and rarely
painful. They may develop late, even after the twenty-first year.
Joint lesions are rare. Glutton has described a symmetrical synovitis
172 SPECIFIC INFECTIOUS DISEASES.
of the knee in hereditary syphilis. Lastly, it must be borne in mind that
enlargement of the spleen may be one of the late manifestations, and may
occur either alone or in connection with disease of the liver. At the
University Hospital, Philadelphia, I had under observation for more than
a year a girl of thirteen, small and feebly developed, with a luetic facies,
whose spleen reached as low as the level of the navel. The condition was
not thought to be due to inherited syphilis until she developed osseous
lesions.
Gummata of the liver, brain, and kidneys have been found in late
hereditary syphilis.
IV. Visceral Syphilis.
A. Syphilis of the Brain and Cord. — The following lesions occur:
(1) Gummata^ forming definite tumors, ranging in size from a pea to
a walnut. They are usually multiple and attached to the pia mater, some-
times to the dura. Very rarely they are found unassociated with the
meninges. When small they present a uniform, translucent appearance,
but when large the centre undergoes a fibro-caseous change, while at the
periphery there is a firm, translucent, grayish tissue. They may closely
resemble large tuberculous tumors. The growths are most common in
the cerebrum. They may be multiple and may even attain a consid-
erable size without becoming caseous. Occasionally gummata undergo
cystic degeneration. In the cord large gummatous growths are not so
common. In an instance recently reported by me a tumor, from three
eighths to one fourth of an inch in diameter, was completely within the
cord opposite the fourth cervical nerve, and there were numerous gum-
mata in the cauda equina.
(2) Gummatous Meningitis. — This constantly occurs in the neighbor-
hood of the larger growths, and there may be local meningeal thickening
several centimetres in extent, in which the pia is infiltrated and the ar-
teries greatly thickened. This by no means uncommon form may run a
subacute or a chronic course.
(3) Gummatous Arteritis. — The lesions may be confined to the arteries
which present the nodular tumors to be described hereafter.
(4) Foci of sclerosis., which Lancereaux holds may be distinguished
from non-specific forms by a much greater tendency of the neuroglia ele-
ments to undergo fatty transformation, and by the secondary alterations,
as areas of softening, which occur in the neighborhood. Neither the dif-
fuse nor the nodular cerebral sclerosis, met with particularly in children,
appears to have any special relation to inherited syphilis.
(5) Whether a localized encephalitis or myelitis can result from the
action of the syphilitic poison without involvement of the blood-vessels is
doubtful. In a case of multiple arterial gummata recently in my ward,
Thomas found in the lumbar region of the cord foci of inflammatory soft-
ening.
SYPHILIS. 173
Svrondinii C/iitni/rs.— \\\ llir Wraiii ^MmiiniitoiiH iirtrritlM Im ono of tliu
(Mxiiiiioii cHiisrs of K<)fUMlill^^ wliirji may 1)0 uxUMiMivc, UK wlu'ii thu fiii<l(llo
(utn^bnil Hi'tiiry Ih involved, mi- u Inn tlicro iri u lar^o patch of iiyphilitif;
rmuiiii^jitis. In hiicIi iiiHtjiiu'cM the picxM'HH in n-iilly ii mi'u\i\^n'i'U<v\i\ii^
litis, Hiwl tli(^ HymploMiM jinMliu* to tin- Hcnoinliiry clmii^'rH in tin* hniin-Miil).
sUmci*, not diriTtly to the ^iininia. in the n('i;^h)>orltooii of a ^iiinrnatoiiH
growth inteuMo encephalitis or niyehtis nniy (lcveh)p, an<l within u tv.w
(liiyH (duin<^(i the clinical pi(;tnre. (iiininnitouH artcritiH intiv lead to woak-
iMiin^ of the wall of the vessri and rnptnie with nienin^'cal haTnorrha^o.
Svphililic disi'use of the nerve-centres nniy occur in the inheriti'd or
acfjuired f(>riii, most coinnioidy in the latt«'r. In the (Minp-nital cases tho
tumors usually devi'lop early, hut may he as late us the twenty-lirst year
(11. ('. Wood). In lluMUMpiircd form the nervo lesions belong, iw u rulo,
to tho late manifestations, and patients may huve (piile forgotten the ex-
istence of a primary infection, and in very numy instunceH the sec.'ondary
manifestations liave been slight, lleuhner, to wlioin we owe so much in
oonniH'tion witli this subject, has t^vvn it as late as the thirtieth year. On
the other hand, in excei)tional instances, it may occur very early, and con-
vulsions and brain symptoms have been reported within three months of
the primary sore. In one of my cases, in which there was endarteritis
followed by dilatation anil perforation, the })atient had had a hard chancre
eighteen months before, with severe secondary symptoms.
Si/)))pfo)ns. — The chief features of cerebral syphilis are those of tumor,
wliich will be considered subsequently under that section. They may be
classitied here as follows :
(1) Psychical features. A sudden and violent onset of delirium may
be the first symptom. In other instances prior to the occurrence of
delirium there have been headache, alteration of character, and loss of
memory. The condition may be accompanied by convulsions. There may
be no neuritis, no palsy, and no localizing symptoms.
(2) More commonly following headache, giddiness, or an excited state
which may amount to delirium, the patient has an ej^ileptic seizure or de-
velops hemiplegia, or there is involvement of the nerves of the base. Some
of these cases display a prolonged torpor, a special feature of brain syphi-
lis to which both Buzzard and Ileubner have referred, which may persist
for as long as a month. II. C. Wood describes with this a state of au-
tomatism occurring particularly at night, in which the patient behaves
like "a restless nocturnal automaton rather than a man."
(3) A clinical picture of general paralysis — dementia paralytica. The
question is still in dispute whether this syphilitic encephalopathy, which
so closely resembles general paralysis, is a distinct and independent alYec-
tion. Mickle, who has carefully reviewed the subject, concludes that
syphilis may directly produce the inflammatory changes in the brain, while
in other instances it directly predisposes to this affection. It is a some-
what remarkable feature that the cases which present the clinical picture
174 SPECIFIC INFECTIOUS DISEASES.
of general paresis are most frequently those which have not had any focal-
izing symptoms, and they may not have convulsions until tlie disease is
well advanced. Another peculiarity is the fact that, like the late sclerosis,
the condition is not very amenable to the specific treatment ; though
Mitchell mentions an instance which he regarded as general paresis, but
which subsequently came into the hands of II. C. Wood, who cured the
case with iodide of potassium.
(4) Many cases of cerebral syphilis display the symptoms of brain
tumor — headache, optic neuritis, vomiting, and convulsions. Of these
symptoms convulsions are the most important, and both Fournier and
Wood have laid great stress on the value of this symptom in persons over
thirty. The first symptoms may, however, rather resemble embolism or
thrombosis ; thus there may be sudden hemiplegia, with or without loss of
consciousness.
The symptoms of spinal syphilis are extremely varied and may be
caused either by large gummatous growths attached to the meninges, in
which case the features are those of tumor ; or by meningitis with secon-
dary spastic changes ; or again by scleroses developing late in the disease,
the relation of which to syphilis is still obscure.
Diagnosis. — The history is of the first importance, but it may be ex-
tremely difficult to get a reliable account. Careful examination should be
made for traces of the primary sore, for the cicatrices of bubo, for scars of
the skin eruption or tliroat ulcers, and for bone lesions. The character
of the symptoms is often of great assistance. They are multiform, vari-
able, and often such as could not be explained by a single lesion ; thus
there may be anomalous spinal symptoms or involvement of the nerves of
the brain on both sides. And lastly the result of treatment has a definite
bearing on the diagnosis, as the symptoms may clear up and disappear
with the use of antisyphilitic remedies.
B. Syphilis of the Lung.
This is a very rare disease. During twenty years I have not seen more
than half a dozen specimens in which there was no question as to the
nature of the trouble. Early in my professional life I learned to recognize
the disease from the teaching of Wilks, and became familiar with the ex-
cellent specimens preserved at Guy's Hospital. In my ten years' work in
Montreal not a single specimen was recognized at the dissections at the
General Hospital. In 1878 and 1884 I saw several characteristic examples
in London and Germany. During five years in Philadelphia, for the
greater part of which time I was connected with the Philadelphia Hospi-
tal, which has perhaps as rich luetic material as is to be found anywhere,
only one or two specimens were seen. Three admirable illustrations of
pulmonary gummata have occurred at the Johns Hopkins Hospital during
the past two years. I mention these details because the subject is one
which has always interested me, and I have been constantly on the lookout
for the disease. It has been a continual surprise that it should be so com-
SVI'IIILIS. 175
Hum \n rovinlw IncalitirH, hut I IiikI tluit my fXjMTirrK'o tin to ilH rompnnu
tiv(< raiily lullirM vny cloHcly with timt (»f juitlinln^'iMtH iiiul lioMpitul pliyni-
ciuiiM ill tliin <ninitry and in Kiirn|M>. Tliu liliTutiiro of i\w Mubjcct if
oxtiMiHivr, lull finm tli(» cliiiicjil iiH|M'ct liir;(rly worlhlfHri, uh it j>rf<;cMlj*<l
Koch's (liHcovcry nf \\w hiirillus tuhi'rrnUiMiM.
I'HioUtiHI and Morhiit .1 //^//<'/////. — Sy|»hiliH of thi; luii^ o(!ciirH under
thr fdUowiiii^ forms :
(1) 'V\\v triiitr piiffnnofUft of tlir J'irl iis. This nuiy iilTc<'t hir^o arcai
or an cnlirc liin^', wliicli then is llrm, hnivy and uirh-ss, even tliou^h tho
child may liavc l>ccn horn alive. On Hcc^tion it hus u ^niyisli-whitij Jippcar-
anco — the so-cullcd white hcj)iitization of Virchow. The chief (;hun^o is
in the alveolar walls, which are greatly thickcne(l and infiltrated, so that,
as Warner expressed it, the condition resemhles a (lilTus(? syphiloma. In
the early stai^es, for example, in a seven or eight months' fo'tns, there may
bo scattered miliary foci of this induration chiefly about tho arteries.
The air-cells arc lillcd with (les(pKimatc<l and swollen epithelium.
(2) In tin* form of definite (jununata^ which vary in size from a pea to
a <]^oose-e<xg. Tiiey occur irrei^ularly scattered througli the lung, but, as
a rule, are more numerous toward the root. They present a grayish-yellow
caseous a})pearance, are dry and usually imbedded in a translucent, more
or less firm, connective tissue. In a case from my wards recently described
by Councilman, there was extensive involvement of the root of the lungs.
Bands of connective tissue passed inward from the thickened pleura and
between these strands and surrounding the gummata there was in places
a mottled red pneumonic consolidation. In the caseous nodules there
is typical iiyalino degeneration. Councilman describes as the primary
lesion, atrophy of the alveolar walls with hyaline degeneration of the capil-
laries, not tlie syphilitic endarteritis, which is well marked, and to which
the lesions are attributed. The bronchi are usually involved, and sur-
rounding the gummata there may be a diffuse broncho-pneumonia, which
does not appear to have any peculiar characters.
(3) A majority of authors follow Virchow in recognizing the fibrous
interstitial pneumonia at the root of the lung and passing along the bron-
chi and vessels as probably syphilitic. This much maybe said, that in cer-
tain cases gummata are associated with these fibroid changes. Again, this
condition alone is found in persons with well-marked syphilitic history or
with other visceral lesions. It seems in many instances to be a purely
sclerotic process, advancing sometimes from the pleura, more commonly
from the root of the lung, and invading the interlobular tissue, gradually
producing a more or less extensive fibroid change. It rarely involves
more than a portion of a lobe or portions of the lobes at the root of the
lung. The bronchi are often dilated.
SymjJtoms. — Is there a syphilitic phthisis, an ulcerative and destruc-
tive disease, due to lues ? Personally I have no knowledge of such an
affection, either clinically or anatomically, and the cases which I have seen
176 SPECIFIC INFECTIOUS DISEASES.
demonstmtcd do not seem to me to have characters distinctive enough to
separate them from ordinary tuberculous phthisis. Certain French writers
recognize not only a chronic syphilitic phthisis but an acute syphilitic
pneumonia in adults, simulating acute pneumonic phthisis. Clinically,
pulmonary syphilis is not of much importance, as the cases can rarely be
diagnosed, and the symptoms which arise are usually those of bronchi-
ectasis or of chronic interstitial pneumonia. The white pneumonia is
usually found in the still-born.
Diagnosis. — It is to be borne in mind, in the first place, that hospital
physicians and pathologists the world over bear witness to the extreme
rarity of lung syphilis. In the second place, the therapeutic test upon
which so much reliance is placed is by no means conclusive. With pul-
monary tuberculosis there should now be no confusion, owing to the readi-
ness with which the presence of bacilli is determined. Bronchiectasy in
the lower lobe of a lung, dependent upon an interstitial pneumonia of
syphilitic origin, could not be distinguished from any other form of the
disease. In persons with well-marked syphilitic lesions elsewhere, when
obscure pulmonary symptoms occur, or if there are signs of chronic inter-
stitial pneumonia with dilated bronchi, and no tubercle bacilli are present,
the condition may possibly be due to syphilis. So far as my experience
goes, tuberculous phthisis occurring in a syphilitic subject has no special
peculiarities. The lesions of syphilis and tuberculosis could of course co-
exist in a lung. Since writing the above, the recent paper of Satterthwaite
has appeared, but not one of the cases upon wdiich it is based could prop-
erly be regarded as syphilitic in the absence of an examination for tuber-
cle bacilli. Much more suggestive of true syphilitic phthisis is Case I of
McLane Tiffany's series, but it too may have been tuberculous. It is quite
possible that a large caseous gumma may break down and form a cavity,
but the existence of an extensive ulcerative and destructive disease of
the lungs (comparable to tuberculosis) due to syphilis has not yet been
proved.
c. Syphilis of the Liver.
This occurs in three forms: (a) Diffuse Syjjhililic Hepatitis. — This is
most common in cases of congenital syphilis. The liver preserves its
form, is large, hard, and resistant. Sometimes it has a yellow look, com-
pared by Trousseau to sole-leather, or an appearance not unlike the amy-
loid liver. Careful inspection shows grayish or whitish points and lines
corresponding to the interlobular new growth. Microscopically, great
increase in the connective tissue is seen, and in many places foci of small-
celled infiltration. Sometimes these nodules are visible, forming firm
miliary gummata which in cicatrizing produce more or less deformity.
Larger gummata may also be present.
(/j) Gummnfa. — As a result of congenital syphilis these may occur in
childhood or in adult life. In acquired syphilis they rarely come on be-
fore the second year after infection. In the early stage there are pale
sYi'iin.is. 177
l^ruyisli iHnliilcH, vuryiii;^' in Mi/f finm u pni lo u imirhhj. Tho larger,
wliirli iuc iiHimlly liinil«'(| hiwiinl llm liver tinHiio, pn'Mniit yellowiuh c«ri-
U'vH III. lirsl ; ImiI later thrre in u " pjiln ycllowiMli, (!li<?fM45-liki5 luxlulo of
irn^^iilar (nilliiic, HmT<»iiinlt'(l liy >i lil.»roiiH /oin», tlm oiiU?r cd^o of which
h)H()H itH(<ir ill \\w lohiiliir tiHHuc, iho 1o))ii1«'h liwiiiillin^ ^'rudniiily in iU
^nisj). 'I'll is lihroiis zoim is rirvcr very hnnul ; tin- rlnTMy rerilro vurieM in
coiisisiciici' fiom 11 ^n-istlu-liku toii^'lincHH to u j>iil|»y Hoftru-HH ; it in hoiiiu-
times iiiortur-iiivc, frniii cn'tacoouH (•hiui;,^' " (Wilks). WIhti niiiiierouM,
I lie most cxlciisivi" (Icforfiiiiy of tin- liver is pruducrd in tho ^nultiul haul-
ing of thi'so ^imimatji. Oil lli(5 HurfiK-e tluTC! aro dcfp, H(;ar-likc5 (Jrprci*-
HJons, nnd tli(« entire or^^Mii may l)e divideci into h chintcr of irrej^ulur
masses, lu'Id t<>«^'etlier by liln-ous tissue. To thin condition th(r term fjaiy-
roid has been ^'iven, from its resemhlaiiee to a l)uneli of grapes. As a
rule, tlic giimmata j^'radually undergo lil)r<)id transformation. 'J'hoy may,
lioweviM", s(»ft(Mi and iKjiiefy, and, according to Wilks, may form a Ihictu-
ating tumor.
(r) Occasionally tlio syphilitic changes arc chielly manifeste<l in (/lis-
son\'< sltvath^ in a thickening of the capsule, j)roducing j)eri-hepatitis, and
increase in the connective tissue in the portdl auuils^ so that on section
tho organ presents a number of branching fibrous scars which may cause
considerable tie form ity.
Symptoms. — The symptoms of syphilitic hepatitis are very variable.
In tlie new-born icterus is not uncommon, but the condition of the liver
can scarcely be recognized. In the adult there are two groups of cases :
The patient presents a picture of cirrhosis of the liver; there are
digestive disturbances, slight icterus, loss of weight, and ascites. If signs
of syphilis are present in other organs, the condition may be suspected,
or if after removal of the fluid the liver is felt to be extremely irregular,
the diagnosis may be made almost with certainty. As these cases, with
proper treatment, may recover, they form a certain contingent of the
cases reported as recovery in ordinary cirrhosis of the liver.
In a second group of cases the patient is ana?mic, passes large quan-
tities of pale urine containing albumen and tube-casts ; the liver is en-
larged, perhaps irregular, and the spleen also is enlarged. Dropsical symp-
toms may supervene, or the patient may be carried olf by some intercurrent
disease. Extensive amyloid degeneration of the sj^loen, the intestinal mu-
cosa, and of the liver, with gummata, are found.
The diagnosis of syphilis of the liver is very important, since upon it
the proper treatment depends. If with a history of infection the liver
is enlarged and irregular, and the general health fairly good, the con-
dition is probably syphiloma. Occasionally tumors of a definite form may
be produced by the gummata. For two years I showed repeatedly, at my
clinic at the University Hospital, Philadelphia, a boy aged eleven, who
had a prominent tumor in the epigastrium connected with the liver, the
nature of which was obscure until well-marked bone-lesions developed.
178 SPECIFIC INFECTIOUS DISEASES.
In another case, a man, aged thirty, was sent to me for advice concerning
the making of an exploratory incision to determine the nature of a firm,
irregular tumor which occupied the epigastric region, and was evidently
connected with the left lobe of the liver. It had lasted for more than a
year, had increased slightly, and had not impaired, to any marked degree,
the general health. This fact, together with a well-marked history of
acquired syphilis, led me to place him upon a rigid antisyphilitic treat-
ment, with the result that within six months the entire tumor disappeared.
D. Syphilis of the Digestive Tract.
The cesopJiagus is very rarely affected. Stenosis is the usual result.
Gummata of the stomach occur occasionally. Syphilitic ulceration has
been found in the stomach, in the small intestine, and in the caecum.
The most common seat of syphilitic disease in this tract is the rectum.
The affection is found most commonly in women, and results from the
development of gummata in the submucosa above the internal sphincter.
The process is slow and tedious, and may last for years before it finally
induces stricture. The symptoms are usually those of narrowing of the
lower bowel. The condition is readily recognized by rectal examination.
The history of gradual on-coming stricture, the state of the patient, and
the fact that there is a hard, fibrous narrowing, not an elevated crater-like
ulcer, usually render easy the diagnosis from malignant disease. In medi-
cal practice these cases come under observation for other symptoms, par-
ticularly amyloid degeneration; and the rectal disease may be entirely
overlooked, and only discovered post mortem.
E. Circulatory System.
Syphilis of the Heart. — A fresh, warty endocarditis due to syphilis is
not recognized, though occasionally in persons dead of the disease this
form is present, as is not uncommon in conditions of debility. Outgrowths
on the valves in connection with gummata have been reported by Jane way
and others, and in Lang's* monograph there are thirteen cases which he
reports as syphilitic endocarditis, most of them of the fibrous or sclerotic
variety.
Syphilitic myocarditis appears either in the form of diffuse fibroid in-
duration or as definite gummata. Lang has collected many cases from the
literature, a majority of which were of the former description. Gummata,
however, occur not infrequently as definite and characteristic tumors in
the myocardium. Rupture may take place, as in the cases reported by
Dand ridge and Nalty, or sudden death, as in the cases of Cayley and Pearce
Gould.
Syphilis of the Arteries. — Syphilis is believed to play an important
role in arterio-sclcrosis and aneurism. Its connection with these processes
will be considered later ; here we shall refer only to the syphilitic arteri-
tis. This occurs in two forms :
* Die Syphilis des Ilerzens, Wien, 1889.
svi'iiiLis. 179
((t) All ithlihrnlimi riiil<trhrihs,v\\\iviivU'YmH\ hy n prolifcrution of tlio
hiiIxmkIoI Ik lial lisHlu^ 'I'lir imiw growth liim witliifi the oluMlic luiiiiiiu, uikI
iiuiy ^niiliiall\ lill lii«- niiirr Iiitiini ; Ikmk'o tlii) t4*rtii oiilitcrutiii^. Thu
iiUMliii uiiii inUriii il ia urc also inliltriitrd with hiiiuII <'ullii. 'I'luM form of
tmdiirtri'it is drsciibril l>y IIimiIuht is imt, linwcvrr, clmnu'tiTiHtij; of HVplii-
lis, iiiul its |)i'('S(<iu'(> aloiir ill lui artery coiiM imt Ix; coiiHiiliTiMl puthog-
iioiiinnic. If, li(>\V('\<i-, lli**i-t< iin^ ^MiiMiiiiitii ill otiior jiiirlH, or if llio coii-
(lilinii al)niil to l)c (It'scrihiui cxistH in adjacriit artcrii'M, tin; j)ro<;fHH may
lu' regarded as sypliilitic.
(/>) (I Kiiinutfiins rn'i-<n'trrilis. — Willi or without involvt^mfiit of tho
iiitiiiia, nodular !j:iiiiniiata may dcvclnp in ilic udvrntitiu f)f tho artery,
pr()du('iii«j^ «,dol)ular or ovoid swell iiii^s, which may attain considcnililc nize.
They aiv not infriMjiuMitly seen in the ccrchral urti-rii'S, which wcm to bo
specially prone to this alTection. This forin is specilic and <listinetivo
of syphilis. The disease usually alTects tho snudler vessels and nuiy Ikj
found in the coronary arteries, and partiimlarly in tliose of the hraiii.
F. Renal Syphilis. — (Jummata occasionally (h^velop in the kidneys,
particularly in cases in which there is extensive gummatous liejiatitis.
They are rarely numerous, and oecasionally lead to scattered cicatrices.
Olinieally the alTcction is not recognizable.
o. Syphilitic Orchitis. — This alTection is of special significance to tho
physician, as its detection frequently clinches the diagnosis in obscure
internal disorders. Syphilis occurs in the testes in two forms:
[a) The (lunimatous (jroirtli^ forming an indurated mass or grouj) of
masses in the substance of tho organ, and sometimes ditlicult to distin-
guish from tuberculous disease. Tlic area of induration is harder and it
atlects the body of the testes, while tubercle more commonly involves the
epididymis. It rarely tends to invade the skin, or to break down, soften,
and sup})urate, and is usually paiidess.
(/;) There is an infersfifial orrhifis regarded as syphilitic, which leads
to fibroid induration of the gland and gradually to atrophy. It is a slow,
progressive change, coming on without pain, usually involving one organ
more than another.
General Diagnosis of Syphilis. — Tliere is seldom any doubt
concerning the existence of syphilitic lesions. The negative statements
of the patient must be taken with extreme caution, as persons will lie
deliberately with reference to primary infection, when it is in their best
interest to make a straightforward truthful statement. It is to be re-
membered that syphilis is common in the community, and there are prob-
ably more families with a luetic than with a tuberculous taint. It is pos-
sible that the primary sore may have been of trifling extent, or urethral
and masked by a gonorrhoea, and the patient may not have had severe
secondary symptoms, but such instances are extremely rare. Inquiries
should be made into the history to ascertain if the patient has had skin
rashes, sore throat, or if the hair has fallen out. Careful inspection should
180 SPECIFIC INFECTIOUS DISEASES.
be made of the throat and skin for signs of old lesions. Scars in the
groins, the result of buboes, may be taken as positive evidence of infec-
tion (Hutchinson). The cicatrices on the legs are often copper-colored,
though this cannot be regarded as peculiar to syphilis. The bones should
be examined for nodes. In doubtful cases the scar of the primary sore
may be found, or there may be signs of atrophy or of hardening of the
testes. In women, special stress has been laid upon the occurrence of
frequent miscarriages, which, in connection with other circumstances, are
always suggestive.
In the congenital disease, the occurrence within the first three months
of snuffles and skin rashes is conclusive. Later, the characters of the
syphilitic facies, already referred to, often give a clew to the nature of some
obscure visceral lesion. Other distinctive features are the symmetrical de-
velopment of nodes on the bones and the interstitial keratitis.
In doubtful cases much stress is laid by some writers upon the thera-
peutic test, by placing the patient upon antisyphilitic treatment. In the
case of an obstinate skin rash of doubtful character, which has resisted all
other forms of medication, this has much greater weight than in obscure
visceral lesions. I have on several occasions known such marked im-
provement to follow large doses of iodide of potassium that the diagnosis
of syphilitic lesion was greatly strengthened, but the subsequent course
and the post-mortem have shown that the disease was not syphilis.
Prophylaxis. — Irregular intercourse has existed from the begin-
ning of recorded history, and unless man's nature wholly changes —
and of this we can have no hope — will continue. Resisting all attempts
at solution, the social evil remains the great blot upon our civilization,
and inextricably blended with it is the question of the prevention of syphi-
lis. Two measures are available — the one personal, the other adminis-
trative.
Personal purity is the prophylaxis which we, as physicians, are espe-
cially bound to advocate. Continence may be a hard condition (to some
harder than to others), but it can be borne, and it is our duty to urge this
lesson upon young and old who seek our advice in matters sexual. Cer-
tainly it is better, as St. Paul says, to marry than to burn, but if the former
is not feasible there are other altars than those of Venus upon which a
young man may light fires. lie may practise at least two of the five
moans by which, as the physician Rondibilis counselled Panurge, carnal
concupiscence may be cooled and quelled — hard work of body or hard
work of mind. Idleness is the mother of lechery ; and a young man will
find that absorption in any pursuit will do much to cool passions which,
though natural and proper, cannot in the exigencies of our civilization
always obtain natural and proper gratification.
The second measure is a rigid and systematic regulation of prostitu-
tion. The state accepts the responsibility of guarding citizens against
small-pox or cholera, but in dealing with syphilis the problem has been
HVlMilLIS. 181
too roTiiplrx «in<l luis liillicrlo Imlllrd Mohitiori. Om tln« one hiiml, iuMjxv.
li(»M, Hc^^n'^'ulioM, and n'^^iiliilioii air ilillirult if not inipoHMihlu to currv
oiil ; on till) otlirr luind, piit)li(! Hctitiriiciit, in An;;lo-Suxon (!ommuniti<
at h^iHt, in aH yd Itittcrly oppoHcd t(» tltin plan. Wliiltt thin fo<*lin^, though
iinrras()iia))l(>, as I think, in rntilh-d to conHidiTatiorif tliu choi(M) litrH In*-
t\vt»(Mi two evils — licensing, ovrn iniprrfcctly <'arri«'<l out, or widc-Hprcud
(lis('ast> and misery. If the ofTrndrr hon* the (Tomh alono, I woidd wiy,
forbear; hut the physician l)ehin<l the seencs knowH that in eoiinth'KH in-
staneeH syphilis has wrought havoc! arnon;^ innocent niothcrH and lielplcHM
infants, often cnlailinL,' life-Ion^ sulTerin^'. It i.s for them In; udvr>cat<*H
prot(M't ive measures.
Treatment. — We must admit that various orj^anizalionH reaet very
dilTeriMitly to the poison of syphilis, '{'here are individuals wIh), althou;(h
reeeivin«; brief and unsatisfaet(>ry treatment, dis])lay for years no tra^.-CH of
the disease. On the other hand, there are persons thoroughly and bvb-
tomatically treated from th(» outset who display from time to time well-
marked inilications of tlie disease. Certainly there are grounds for the
opinion that persons who have sufTered very sli<(htly from secondary
symptoms are more juone to have tlio severer visceral lesions of the later
sta^e.
When we consider that syphilis is one of the most amenable of all dis-
eases to treatment, it is lamentable that the later stages which come under
the charge of tlie j)hysician are so common. Tliis results, in great part,
from carelessness of the patient, who, wearied with treatment, cannot un-
derstand why he should continue to take medicine after all the symptoms
have disappeared ; but, in part, tlie profession also is to blame for not
insisting more urgently in every instance that acquired syphilis is not
cured in a few months, but takes at least two years, during which time
the patient should be under careful supervision. The treatment of the
disease is now practically narrowed to the use of two remedies, justly
termed specifics — namely, mercury and iodide of potassium. The former
is of special service in the secondary, the latter in the tertiary manifesta-
tions of the disease; but they are often combined with advantage.
Mercury may be given by the mouth in the form of gray powder, the
hydrargyrum cum creta, which Hutchinson recommends to be given in
pills, one-grain dose with a grain of Dover's powder. One pill from four
to six times a day will usually sutHce. I warmly endorse the excellent
results which are obtained by this method, under which the patient often
gains rapidly in weight, and the general health improves remarkably. It
may be continued for months without any ill effects. Other forms given
by the mouth are the pilules of the biniodide (gr. j^), or of the protiodide
(gr. ^), three times a day.
Inunction is a still more effective means. A drachm of the ordinary
mercurial ointment is thorous^hlv rubbed into the skin every evenins^ for
six days ; on the seventh a warm bath is taken, and on the eighth the mer-
182 SPECIFIC INFECTIOUS DISEASES.
curial course is resumed. At least half an hour should be given to each
inunction. It is well to apply it at different places on successive days.
The sides of the chest and abdomen and the inner surfaces of the arms
and thighs are the best positions.
The mercury may be given by direct injection into the muscles. If
proper precautions are taken in sterilizing the syringe, and if the injec-
tions are made into the muscles, not into tlie subcutaneous tissue, ab-
scesses rarely result. One third of a grain of the bichloride in twenty
drops of water may be injected once a week, or from one to two grains of
calomel in glycerin (20 minims).
Still another method, greatly in vogue in certain parts of the Continent
and in institutions, is fumigation. It may be carried out effectively by
means of Lee's lamp. The patient sits on a chair wrapped in blankets,
with the head exposed. The calomel is volatilized and deposited with
the vapor on the patient's skin. The process lasts about twenty minutes,
and the patient goes to bed wrapped in blankets without washing or dry-
ing the skin. A patient under mercurial treatment should avoid stimu-
lants and live a regular life, not necessarily abstaining from business.
Green vegetables and fruit should not be taken. Salivation is to be
avoided. The teeth should be cleansed twice a day, and if the gums be-
come tender, the breath fetid, or the tongue swollen and indented, the
drug should be suspended for a week or ten days.
In congenital syphilis the treatment of cases born with bullae and other
signs of the disease is not satisfactory, and the infants usually die within a
few days or weeks. The child should be nursed by the mother alone, or,
if this is not feasible, should be hand-fed, but under no circumstances
should a wet-nurse be employed. The child is most rapidly and thor-
oughly brought under the influence of the drug by inunction. The mer-
curial ointment may be smeared on the flannel roller. This is not a very
cleanly method, and sometimes rouses the suspicion of the mother. It
is preferable to give the drug by the mouth, in the form of gray powder,
half a grain three times a day. In the late manifestations associated
with bone lesions, the combination of mercury and iodide of potassium
is most suitable and is well given in the form of Gilbert's syrup, which
consists of the biniodide of mercury (gr. j), of potassium iodide ( 3 ss.),
and water ( 3 ij). Of this a dose for a child under three is from five to
ten drops three times a day, gradually increased. Under these measures,
the cases of congenital syphilis usually improve with great rapidity. The
medication should be continued at intervals for many months, and it is
well to watch these patients carefully during the period of second dentition
and at pu))erty, and if necessary to place them on specific treatment.
In tlic treatment of the visceral lesions of syphilis, which come more
distinctly within the province of the physician, iodide of jootassium is of
equal or even greater value than mercury. Under its use ulcers rapidly
heal, gummatous tumors melt away, and we have an illustration of a spe-
SYIMIIUS. 183
cillc u(Mi(»ii only (mjuuIIimI l»y llmt (»f inrn-ury in the Mrcornliiry mIu^mh, by
iron in (crhiin foriiiH of iiiiii'miu, uikI )>y (|uininn in tniiluriii. Il in uii a
ruh< well Itoino in un initiiil dose of ten j^'ruinM, or ten niininiM of tin* Miitii-
nitod HoIutioM ; ^mvco hi inillv tlx' |ialiriit <I<m'h not notict* tin; UihU'. Il
h))ou1(I )u' ^nulually incrciiHiMl to thirty or more ^rainH tltrce tirncH u iluy.
In Kyphilis of tlw iicrvouH HyHtrni il nniy ho UHud in Htiii hir^cr (Iohch.
Sc^Miiii, who has sjHM-ially insisted ii|m»m lh«' advantji^'o of thin phin, nr^'en
that the dni^' should \)v jmsh«'d, as good i-lTi'cts an* not ohtain«'<l witli tho
nioih'rali' (h)S('s.
When syphiliiic hepatitis is Husju'ctrd tlic conihinatioM of mercury und
iodith' of p(>tas>iiini is most satisfaetory. If there is Jun;iteH, Aihlison's or
Niemeyer's pill (as it is often ealle(l) of calomel, digitalis, and H<piills will
he found very useful. A patient of mine with recurring ascites, on whom
paracentesis was repeatedly pcrfornu'd and who had an enlarge<l and irregu-
lar liver, took this pill for more than a year with occasional interndssions,
and ultimately there was a complete disappearance of tiie dropsy und an
extraordinary reduction in the volume of the li?er. Occasionally tho
iodide of sodium is more satisfactory than the iodide of potassium. It is
loss depn\^sing and agrees hetter with the stomacli. Many patients possess
a renuirkable iiliosyncrasy to the iodide, but as a rule it is well borne.
Severe coryza with salivation, aiul cedenui about the eyelids, are its most
common disagreeable elTects. Skin eruptions also are frequent. I liave
known patients unable to take more than from twenty to thirty grains
without suffering from an erythematous rash ; much more common is the
acne eruption. Occasionally an urticarial rash may develop with spots of
purpura. Some of these iodide eruptions may closely resemble syphilis.
Hutchinson has reported instances in which they have proved fatal.
Upon the question of sypliilis and marriage the family physician is
often called to decide. He should insist upon the necessity of two full
years elapsing between the date of infection and the contracting of mar-
riage. This, it should be borne in mind, is the earliest possible limit, and
there should be at least a year of complete immunity from all manifesta-
tions of the disease.
In relation to life insurance, an individual with sypliilis can not be
regarded as a lirst-class risk unless he can furnish evidence of prolonged
and thorough treatment and of immunity for two or three years from all
manifestations. Even then, when we consider the extraordinary frequency
of the cerebral and other complications in persons who have had this dis-
ease and who may even have undergone thorough treatment, the risk to
the company is certainly increased.
13
184 SPECIFIC INFECTIOUS DISEASES.
XXVI. TUBERCULOSIS.
I. General Etiology and Morbid Anatomy.
Definition, — An infective disease, caused by tlie bacillus tuberculosis^
the lesions of which are characterized by nodular bodies called tubercles
or diffuse infiltrations of tuberculous tissue which undergo caseation or
sclerosis and may finally ulcerate, or in some situations calcify.
Etiology. — 1. Zoological Distribution. — Tuberculosis is one of the
most wide-spread of maladies.
In cold-blooded animals it is rare, owing doubtless to temperature
conditions unfavorable to the development of the bacillus. Among rep-
tiles in confinement it is, however, occasionally seen (Sibley). In fowls it
is an extremely common disease, but recent facts indicate that there are
differences in avian tuberculosis sufficient to warrant its separation from
the ordinary form.
Among domestic tinimals tuberculosis is widely but unevenly dis-
tributed. Among ruminants, bovines are chiefly affected. The statistics
of the Berlin abattoir show that in the years 1887-'88 tuberculosis was
found in 4,300 cattle. In this country it is extremely difficult to get
satisfactory statistics of the prevalence of the disease. At the meeting of
the United States Veterinary Medical Association in 1889, it was stated
in a resolution that from ten to fifteen per cent of the dairy stock of the
Eastern States was tuberculous.
In Baltimore, A. W. Clement, United States veterinary inspector, in-
forms me that of 5,297 cattle slaughtered in Maryland only 159 were
tuberculous.
In sheep the disease is very rare. In pigs it is common, but not so
common in this country as in Europe. In the inspection of one thousand
hogs, which was made by A. W. Clement and myself in Montreal in 1880,
tuberculosis was seen only once or twice. At the Berlin abattoir in
1887-'88 there were 6,393 pigs affected with the disease.
Horses are rarely attacked. Dogs and cats are not prone to the disease,
but cases are described in which infection of pet animals has taken place
from phthisical masters. Among the semi-domestic animals, such as the
rabbit and guinea-pig, the disease under natural conditions is rare,
although these animals, particularly the latter, are extremely susceptible
to the disease when inoculated. Among apes and monkeys in the wild
state, tuberculosis is unknown, but in confinement it is the most formi-
dable disease with which they have to contend.
The important etiological fact in connection with tuberculosis in ani-
mals is the wide-spread occurrence of the disease in bovines, from which
class we derive nearly all the milk and a very large proportion of the
meat used for food.
2. Geographical Distribution.— The disease exists in all countries. It
proviiilH inorr in tlio lur^o oiti(*H and wlirrcvfr \ho jiojmliition in ihummmI
lo^'ctlicr. 'riiiiM, \\\\\\o tli(< ^<»n<'rul drHlli-nih* from it jh tlirc;o jmt thoii-
suiid, tluit of \'icMiiii is 7-7, und of Miinicli and (ila^^^iw four )mt ihoiiMarid.
Ilirsch, fidtn whose classical work tliC'Sc facts arc takrn, tliiiikM that ^iro-
^'raphical j)osilinii has less irilliiciHHt than han bcrii Hii)>pohcd. Italy and
Kn^daiul siilTci- alike, niid the diseaHo in very prevalent in tlu! WcHt IndieH
and the South Sea islands. 'I'oward tlie poles it in rare, it in a common
diseasi? in Cunaila, and prevails extensively ainon^' the French ('anadiariH
and (lie Mn^^dish. Altitude is a more ])otent factor than latitwd(s In the
high re<(ions of the Alps and Andes, and in the central plateau of Mexico
the disease is very rare. Mountainous countries, such as Switzerland, have
a very low death-rate fi-oui tuherciihhsis.
i{. Race.— N(» raet^ is immune, 'i'he Indians of this continent are
very prone to the disease. Matthews, whose e.\])erience with the native
race is lar«:^e, states that the disease is on the increase amon<( them. He
quotes tlie ratio from the United States census, ISJSO, as wliite 100,
ne<xi'oes 18(1, Indians 2S(). 'J'he death-rate in the older reservations, as
in New ^'orU, is three times as great as in Dakota. In the IMood Indian
Reserve of the Canadian Nortliwest Territories, Surgeon Kennedy
(N. W. M. 1*.) has given me the figures for six years. In a poj)ulation of
about 2,000 tliere were 127 deaths from {)ulm()nary consumpti(jn, twenty-
three per cent of the total rate. This does not include deaths from
"diseases of infancy." This enormous death-rate, it is to be remembered,
occurs in a tribe occupying one of the finest climates of the world among
the foot-hills of the Rocky Mountains, a region in which consumption is
extremely rare among the white population, and in which cases of tuber-
culosis from the eastern provinces do remarkably well.
The negro race is very susceptible to tnberculosis, more particularly the
glandular and osseous forms. Of the 427 cases of pulmonary tuberculosis
at the Johns Hopkins Hospital for the two years ending June 1, 1891,
there were 41 cases in the colored — i. e., about 1: 10. The ratio of colored
to white of all patients in the wards has been 1 to 7.
4. The Bacillus Tuberculosis. — The history of the discovery of the
bacillus presents many points of interest. Confidently expected by such
observers as Villemin, Chauveau, Cohnheim, and others, and claimed to
have been demonstrated by many, notably by Klebs and Aufrecht, it re-
mained for Koch to demonstrate its existence and its invariable association
with the disease. The investigations which he had previously made upon
anthrax and experimental traumatic infections, by perfecting the methods
of research, paved the way for this brilliant discovery. His preliminary
article * and his more elaborate later work f should be carefully studied by
any one who wishes to appreciate the value of scientific methods. It forms
* Berliner klinische Wochenschrift, 1882.
f Mittheiluiigen a. d. k. Gesundheitsamte, Bd. 2.
180 SPECIFIC INFECTIOUS DISEASES.
one of the most masterly demonstrations of modern medicine. Its thor-
oughness appears in the fact that in the nine years which have elapsed
since its announcement the innumerable workers at the subject have not,
so far as I know, added a solitary essential fact to those presented by Koch.
Moi'pliological Characters. — The tubercle bacillus is a short, fine rod,
often slightly bent or curved, and has an average length of nearly half the
diameter of a red blood-corpuscle (3 to 4 ft). When stained it often pre-
sents a beaded appearance, which some have attributed to the presence of
spores.
With the basic aniline dyes it stains slowly, except at the body tem-
perature, but retains the dye after treatment with acids — a characteristic
which separates it from all other known forms of bacteria, with the excep-
tion of the bacillus of leprosy.
Modes of Growth. — It grows on blood-serum, glycerin-agar, or on po-
tato— most readily on the former. The cultures must be kept at blood-
heat. They grow slowly, and do not appear until about the end of the
second week. The colonies form thin, grayish-white, dry, scale-like masses
on the surface of the culture medium. Successive inoculations may be
made from the cultures, and at the end -of an indefinite series material
from one of them inoculated into a guinea-pig will produce tuberculosis.
Products of the Groicth. — Little is yet known of the chemical charac-
ters of the materials which result from the growth of the tubercle bacilli.
Koch's tuberculin is stated to be a glycerin extract of the cultures. Crook-
shank and Herroun have separated an albumose and a ptomaine.
Distribution of the Bacilli. — The bacilli are found in all tuberculous
lesions ; in some in great abundance, in others sparsely. They are par-
ticularly numerous in actively developing tubercles, but in the chronic
tuberculous processes of lymph-glands and of the joints they are scanty.
When a tuberculous focus communicates with a vein or with lymph-ves-
sels, the bacilli may be spread widely throughout the body. In old lesions
they may not be found in the sections, and the demonstration of the true
nature may be possible only by culture or inoculation.
The Bacilli outside the Body. — Patients with advanced pulmonary
tuberculosis throw off in the expectoration countless millions of the bacilli
daily. Some idea of the extraordinary numbers may be gained from the
studies of Nuttall.* From a patient in my ward, with moderately advanced
disease, the amount of whose expectoration was from seventy to a hundred
and thirty cubic centimetres daily, he estimated by his method that there
were in sixteen counts, between January 10th and ^larch 1st, from one
and a half to four and a third billions of bacilli thrown off in the twenty-
four hours. These figures emphasize the danger associated with phthisical
sputa unless most carefully dealt with. When expectorated and allowed
to dry, the sputum rapidly becomes dust, and is distributed far and wide.
* Johns Hopkins Hospital Bulletin, May, 1891.
'11 r.lI.M LLUSIS. 1R7
'Vhr obHcrvutiouH miu\v l>y Cornrt ihkIit Koch*H 8ii|HTvi«ion ftro in Uhh
cotiiKM't ioM most iiistnictivc. llti colltM'trd tin' diiHi from tin; wuIIh and
IkmIsIcjkIh (»f viiiiniis lociil i I IrM, uikI (IftcrrnitnMl its vinilctict? or iinioriKMiH-
iicsH l)y iiiociilutioM into KiiHC('ptil)l(' uniinalH. Material wiw ^utlnnMi from
t\v('iily-(>iH< wjinlH of Hovcii hoHpitalM, tlin-c iiMyluriiH, two jirinonH, from
tlio Huri<niiulin;^'M of HJxty-two plithiKical patii'iitH in privatr practice,
and fioiii t wpnty-niiir other localiticH in which tulMTculouH put icntn were;
only transient frejjnenter.s (out-patient (h-partrnents, HtrcctH, etc.). Of
one hundred and ei^^diteeii dust sarnph'S from hospital wardH or th<j
rooms of j)hthisi('al patients, forty were infective and j)roduce(i tubcrcu-
h)sis. Nojjjutivo results were obtained with tlu^ twenty-nine dust wimplcH
fi-oni the k)ealities occasionally occupied ])y consumptives. Virulent ba-
cilli were oi)l:iined from tlie dust of the walls of fifteen out of twenty-one
medical wartls. It is interesting to note tlwit in two wards with many
])]ithisieal patients the results were negative, iiulicating that the dust in
such regions is not necessarily infective. The infectiousness of the medi-
cul and surgical divisions of a bospital is in the proportion of 7G*G to 12'5.
In a room in wliicli a tuberculous woman had lived, the dust from the
wall in the lu'ighborhood of the bed was infective six weeks after her
death. No bacilli weiv found in tiie dust of an inhalation-chamber for
consumptives.
The tubercle bacillus is thus a wide-spread organism in regions fre-
quented by phthisical ])atients.
5. Modes of Infection. — ((() Hereditary Traiismission. — In extremely
rare instances the disease is congenital. A few undoubted cases have
been reported in man and in the calf. The rarity with which it occurs
may be gathered from the fact that of 15,400 calves killed at the Berlin
abattoir there were only four instances of tuberculosis. Cases of con-
genital tuberculosis in man have occasionally been described.
Baumgarten holds that in many cases the virus is transmitted, but the
disease does not appear until some time after birth. He bases this opin-
ion upon the following facts :
The great frequency of tuberculosis in sucklings. Thus, in 1G,581 au-
topsies on sucklings, Frobelius found 41 G with tuberculous lesions. In
219 cases of tuberculosis in children under two, from Parrot's clinic,
there were 23 under three months, and a total of 111 under one year.
It seems probable that in many of these cases the virus itself was trans-
mitted.
The common occurrence of tuberculosis in the bones and in the joints
of children, regions to which it seems unlikely that the bacilli would be
conveyed in accidental infection. To make this objection valid we should
require a series of cases of bone tuberculosis in children in which exami-
nation showed the lymph portals of the bronchi and the mesentery to be
free from disease. He reofards the late manifestation as analosrous to the
syphilis hereditaria tarda, and suggests that the growth of the germs is.
188
SPECIFIC INFECTIOUS DISEASES.
A. F.
FEMALE
1783-1887
as a rule, restrained or held in check by the actively developing tissues of
the child.
Tuberculosis unquestionably may be inherited, but in what way and
how often are unsettled problems. Congenital disease is extremely rare,
but there is no inherent improbability in a prolonged latency of the virus.
That it may be present without the existence of actual tubercles is indi-
cated by an experiment of Birch-IIirschfeld, who found that portions of
the viscera of a fcEtus born of a phthisical mother, though not itself
tuberculous, were infective to guinea-pigs.
In any series of cases of pulmonary tuberculosis there is a suspicious
number in which the ascendants have also been tuberculous. Thus, in
427 cases at the Johns Hopkins Hospital there were 53 in which the
mother was affected, 52 in which the father had tuberculosis, and 105 in
which brother or sister had had the disease. The estimates by various
authors range from 10 per cent (Louis), 25 per cent (Walshe), to even 50
per cent. Fagge very justly remarks that it is impossible to draw a line
between hereditary and accidental tuberculosis, and naturally the chil-
dren of an affected par-
ent are more liable to
accidental contamina-
tion. Maternal is very
much more common than
paternal inheritance. A
family tree, such as is
here given, of six gener-
ations tells its own tale.
It is interesting to note
the almost constant
transmission through the
mother.
(b) Inoculation. — The
infective nature of tuber-
culosis was first demon-
strated by Villemin, who
showed conclusively in
1865 that it could be
transmitted to animals
by inoculation. The
question was hotly con-
tested, and Villemin's ob-
servations were confirmed by Simon, Andrew Clark, and others, but Bur-
don Sanderson, "Wilson Fox, and others held that the disease could be
transmitted by non-tuberculous materials. The beautiful experiments
of Cohnhcim and Salamonson, who produced tuberculosis in the eyes
of guinea-pigs and rabbits by inoculating fresh tubercle into the ante-
FEMALE
\
FEMALE J
\ FEMALE
/ \. FEMALE
FEMALE j \
M.V. \
FEMALE y
^ <
A.M.
\ /^P.P.\^
f A.G.\
/^H.R.\ /
E.V.\
/^A.L.\
y E.V.
MALE
J \rtUK\.t.J
\ MALE /
1 I
yrEMALEy
fw G.\
VfemaleV
L FEMALEy \
FEMALEy
I FEMALEy
r)
Vfemale/
V male
Chart XII. — Heredity in pulmonary tuberculosis.
rior chjiinhrr, cofirirnH'tl and rxtorn1«'<| X'illcrfiin'H ()ri;^'ni;ii ob-n tvuLioiijj
UM(1 pavctl tli(^ way f<»r ll»r rcccplinii of Korlj'n aiinoiinmiM-nt. It in
now iiiiivcrsallv coiKM'drd that un/i/ tiil)rn*ul<)iiH iiiattiT can produce, wlwri
iMondalcd, I ii)iri-(iil<»His. In man t iil)cn'id(iHi.M in not ofti'ii trunitriiit-
ted l)v inociilat ion, aiiti w lim it dors ocrnr tin- disciiH** iiHimlly rcrnuiriH
local. 'J'liis mode <d' infrctioii in Hfcii in pernonH wlwmo occupiition brings
tlu-ni in contact with dead hodics or animal protliictH. DcrnonHtratorH of
nioihid anatomy, hutchcrs, and handlers of hides are snhject to a locui
tuherclc of thi^ skin, which forms a reddene(l mass of ^'rannlation tiHsue,
usnally cappin;^ the dorsal snrfaces of the hands or lin^'crH. 'J'Imh Ih the
80-called post-mortem wait, the rrrrura fitcrnf/r/iird «.f W'ilks. 'I'Ihj dem-
onstration of its nature ia shown l)y tlie presence of tubercle bacilli, and
by inoculation expeiiments in animals.
The statement that iiaennei; contracted phthisis from this source is
probably false, sinc(» he did not die until twenty years after the inocula-
tion and in the interval presented no manifestations. 'J'he j)0.ssibility,
however, of general infection must be borne in mind. (Jerber reports
that after accidental inoculation of the hand from a case of phthisis
he had for months a *' Leichen-tuberclo," which was excised. Shortly
afterward the lymph-glands of the axilla became enlarged and pain-
ful, and when removed showed characteristic tuberculous changes, with
bacilli.
In the performance of the rite of circumcision children have been acci-
dentally inoculated. Infection in these cases is probably always associated
with disease in the operator, and occurs in connection with the habit of
cleansing the wound by suction.
Other means of inoculation have been described : as the wearing of
ear-rings, washing the clothes of phthisical patients, the bite of a tubercu-
lous subject, or inocuhition from a cut by a broken spit-glass of a con-
sumptive ; and Czerny has reported two cases of infection by transj:)lanta-
tion of skin.
It has been urged by the opponents of vaccination that tuberculosis, as
well as syphilis, may be thus conveyed, but of this there is no evidence,
and the lymph from the vesicles of re vaccinated consumptives has been
shown by many observers to be non-infective. It may be said, on the
whole, that inoculation in man plays a trifling j'ole in the transmission of
tuberculosis.
(c) Infection through the Air. — It has been fully proved that the ex-
pired air of tuberculous patients is not infective. On the other hand, the
virus is contained in enormous amounts in the sputum, which, when dried,
is soon widely disseminated in the form of dust, and unless carefully
sterilized constitutes a great medium of transmission. A belief in the
contagiousness of pulmonary tuberculosis has existed from the days of the
early Greek physicians, and has persisted among the Latin races.
The investigations of Cornet atford conclusive proof that the dust of a
190 SPECIFIC INFECTIOUS DISEASES.
room or other locality frequented by patients with pulmonary tubercu-
losis is infective. The bacilli are attached to fine particles of dust and in
this way gain entrance to the system through the lungs. The following
are some of the facts in favor of this view :
(1) Primary tuberculous lesions are in a majority of all cases connected
with the respiratory system. The frequency with which foci are met with
in the lungs and in the bronchial glands is extraordinary, and the statis-
tics of the Paris morgue show that a considerable proportion of all persons
dying of accident or by suicide present evidences of the disease in these
parts. The post-mortem statistics of hospitals show the same wide-spread
prevalence of infection through the air-passages. Biggs reports that more
than 60 per cent of his post-mortems showed lesions of pulmonary tuber-
culosis. In one hundred and twenty-five post-mortems at the Foundling
Hospital, 'New York, the bronchial glands were tuberculous in every case.
In adults the bronchial glands may be infected w^hile the individual is in
good health. H. P. Loomis found in eight of thirty cases in which there
were no signs of old or recent tuberculous lesions that the bronchial glands
were infective to rabbits.
(2) The greater prevalence of tuberculosis in institutions in which the
residents are confined and restricted in the matter of fresh air and a free
open life — conditions which would favor, on the one hand, the presence
of the bacilli in the atmosphere, and, on the other, lower the vital resist-
ance of the individual. The investigations of Cornet upon the death-rate
from consumption among certain religious orders devoted to nursing give
some striking facts in illustration of this. In a review of thirty-eight
cloisters, embracing the average number of 4,028 residents, among 2,099
deaths in the course of twenty-five years, 1,320 (62*88 per cent) were from
tuberculosis. In some cloisters more than three fourths of the deaths are
from this disease, and the mortality in all the residents, up to the fortieth
year, is greatly above the average, the increase being due entirely to the
prevalence of tuberculosis. It has been stated that nurses are not more
prone to the disease than other individuals, but Cornet says that of a hun-
dred > nurses deceased, sixty- three died of tuberculosis. The more perfect
the prophylaxis and hygienic arrangements of an asylum or institution,
the lower the mortality from tuberculosis. The mortality in prisons has
been shown by Baer to be four times as great as outside. The death-rate
from phtliisis is estimated at 15 per cent of the total mortality, while in
prisons it constitutes from 40 to 50 per cent, and in some countries, as
Austria, over 60 per cent. Flick has studied the distribution of the deaths
from tuberculosis in a single city ward in Philadelphia for twenty-five
years. Ilis researches go far to show that it is a house disease. About
33 per cent of infected houses have had more than one case. Less than
one third of the houses of the ward became infected with tuberculosis
during the twenty-five years prior to 1888. Yet more than one half of
the deaths from this disease during the year 1888 occurred in those in-
TriiKitcrhosis. UM
fccti'd lioiiHcM. 'riicrc arc, ImwrNcr, «>|i|M»sin;^' factM. Tlir MtatiLi'M <>f thi*
h n Mil p toll ( 'oiiHuniplioM I loMpilal hIiow lliat doc torn, niirHCM, iiml uttciiduntM
arc rarely allackcd. I )ctt\vcilcr claiiiiM that Jio <*aMc of lulxTculoMiM liax
l)ccM colli ractcd aiiioii:^' liis iiiirsi-s or attciidiintM iit I'^ilkciiMU'lii. The
whole (|iicsii(»ii has recently hcen t horoii^dily reviewed by Heron,* in
whose woilv will also he found a li-t of cuhcs of infection (prefmred by
Koch) reporte(| l)ctwccii iHJil and Iss'.i.
(.'{) Spi'cial daii^^M'r exists when the <-oiitact is very intimate, Hiich, for
instance, as between man and wife. On this point mncli dilTerenco of
opinion exists, hut llu' I'lL^nrcs seem to indicate that iimler these circ'um-
Htances the hnshaml of wife is iiiiich iintre liahh^ Bubsequently to die of
consumption. Of ['Vt cases of pulmonary tuberculosis at the .John.s Hoj)-
kins Hospital, in )i^) either husband or wife had been afTected with it f»r
had died of tuberculosis. In responses to a (piestion as to conta^^ion, ii.ske(l
by the Collectivo Investiixation Committee of the British Medical As.soeia-
tion, there were 2(51 replies in the afVirmative, amonf^ which were 158 cases
of supposed contau^ion throuirh mairiaire. Weber's cases are of special
interest. One of his patients lost four wives in succession, one lost three,
and four lost two eacli.
{(/) lufcc/io/i hy Milk. — The milk of an animal su ITeriiiL,^ from tuber-
culosis may contain the virus, and is ca])able of communicating the dis-
ease, as shown by Gerlach, Bang, Bollinger, and others. Striking illustra-
tions of this are sometimes afforded in the lower animals. The pigs, for
instance, of a tuberculous sow have been sbown to present intestinal tubercu-
losis of the most exquisite form. Of late years the experimental proof has
been entirely conclusive. It was formerly thought that the cow must pre-
sent tuberculous disease of the udder, but Ernst has shown that the bacilli
may be present and tbe milk be infective in a large proportion of cases in
which there is no tuberculous mammitis ; an observation made also by
Hirschberger and others. This author states the interesting fact that an
owner of a herd known to be tuberculous withdrew the milk from
market and used it without boiling to fatten his pigs, which, almost with-
out exception, became tuberculous, so that the whole stock had to be
slaughtered. There is no reason to believe that young children or even
adults are less susceptible to the virus than calves or pigs, so that the
danger of the disease from this source is real and serious. The great fre-
quency of intestinal and mesenteric tuberculosis in children no doubt
finds here its explanation. As noted in Wood head's analysis of one hun-
dred and twenty-seven cases of fatal tuberculosis in children, the mesen-
teric glands w^ere involved in one hundred.
(e) Infection hy Meat. — The meat of tuberculous animals is not neces-
sarily infective. The results of experiments with the flesh of cows are
not in accord. This mode of infection probably plays a minor role in the
* Evidences of the Communicabihty of Consumption, London, 1890.
192 SPECIFIC INFECTIOUS DISEASES.
etiology of human tuberculosis, as usually the flesh is thoroughly cooked
before eating. The possibility, however, must be borne in mind, and it
would certainly be safer in the interests of a community to confiscate the
carcasses of all tuberculous animals. Experiments in Bollinger's laboratory
show that the flesh of tuberculous subjects is very infective to guinea-pigs.
6. Conditions influencing Infection. — (a) Co7istitutional Peculiarities. —
It was formerly thought that individuals of a certain habit of body, and of
a certain physiognomy, the habitus phthisicus, were specially prone to
tuberculous disease ; but few now regard the so-called tuberculous or
scrofulous diathesis as more than an indication of a certain type of con-
formation, in which the tissues are more vulnerable and less capable of
resisting infection. In many instances Cohnheim is unquestionably cor-
rect in stating that the so-called phthisical habit is not an indication of a
tendency to, but actually of the existence of, tuberculosis. The belief in
a special phthisical frame has existed in the profession from the days of
Hippocrates, who says, " The form of body peculiar to subjects of phthisi-
cal complaints was the smooth, the whitish, that resembling the lentil ;
the reddish, the blue-eyed, the leuco-phlegmatic, and that with the scapulae
having the appearance of wings." Galen also wrote upon this type of chest
as specially characteristic of the disease. Certainly the long, narrow, flat
chest with depressed sternum is most commonly seen in tuberculous per-
sons, but how common it is also to meet with patients who have well-
formed, well-built chests, with wide costal angle and good pulmonary ex-
pansion ! The investigations of Beneke with reference to the formation
of the viscera in the subjects of phthisis are very interesting. His meas-
urements indicate that the heart is relatively small, the arteries are pro-
portionately narrow, and the pulmonary artery is relatively wider than the
aorta. This point, he suggests, would lead to increase in the blood-press-
ure in the lungs and favor catarrh. The lung volume he found to be
relatively greater in those affected with phthisis.
Galton and Mahomed made observations upon the composite portrait-
ure of phthisis. In 442 patients they separated two types of face; one
ovoid and narrow, the other broad and coarse featured. This corresponds
in an interesting way to the diathetic states formerly recognized — namely,
the tuberculous, with thin skin, bright eyes, oval face, and long, thin
bones ; and the scrofulous, with thick lips and nose, opaque skin, large
thick bones, and heavy figure. These conditions, on which so much stress
was formerly laid, indicate, as Fagge states, nothing more than delicacy
of constitution, incomplete growth, and imperfect development.
(b) Influence of Age. — Tuberculosis occurs at all periods of life, in the
suckling as well as in the octogenarian. The distribution of the lesions
varies greatly at different ages. In the first decade the lymphatic glands,
bones, and meninges are much more frequently affected than at subse-
quent periods. Meningeal tuberculosis is most common between the
third and eighth years.
TUBERCULOSIS. 193
The mesenteric glands are specially prone to be involved in young
children, as before mentioned. Of 127 cases of tuberculosis in children,
Woodhead found these bodies affected in 100 instances, in 14 of which
there were no tubercles in other parts of the body. The majority of these
cases occur between the first and fifth years. The bronchial glands are
still more frequently involved, and of 125 cases at the New York Found-
ling Hospital in every onC/Were these structures the seat of more or less
extensive tuberculosis.
In adults the lungs usually contain tubercle when it is present in the
body (Louis' law).
(c) Soil and locality are held by many to have an important influence
in tuberculosis. The observations of H. I. Bowditch in this country, and
of Buchanan in England, show that pulmonary tuberculosis is more preva-
lent in damp, ill-drained districts ; but this increased incidence is most
probably associated with a heightened vulnerability due to an increased
liability to catarrhal affections of all kinds.
(d) Local Conditions influencing Infection. — These are doubtless of
the highest importance, and second only to the constitutional vulnera-
bility. Among the more important may be mentioned :
Catarrhal Inflammation. — This probably acts by lowering the resist-
ance, or, in modern parlance, reducing the activity of the phagocytes
and allowing the bacilli to pass the portals. The liability of infection
in the cervical and bronchial glands in children is probably associated
with the common occurrence of catarrhal processes in the throat and
bronchi.
The influence of bronchial catarrh in pulmonary tuberculosis is all-im-
portant. How often is it said that the disease has started in a neglected
cold, which means, in other words, that the bronchial catarrh has enfeebled
the power of tissue resistance, or produced conditions favorable to the growth
and development of the bacilli !
An important part in the etiology of tuberculous processes is played
by trauma. Surgeons have for years laid great stress upon this associa-
tion, but the relation, though universally recognized, is by no means easy
of explanation. Bacteriological experiments, however, indicate that in
tissues which have been injured organisms, which would in health have
been readily and rapidly destroyed by the action of the normal juices or
cells, under these altered circumstances grow rapidly and develop. Proba-
bly in the case of tuberculosis following trauma the injured part is for a
time a locus minoris resist ejitice., and if bacilli are present they may by it
receive a stimulus to growth, or under the altered conditions be capable of
multiplying. Not only in arthritis but in pulmonary tuberculosis trau-
matism may play a part. The question has been thoroughly studied by
Mendelsohn,* who reports nine cases in which, without fracture of the
* Zeitsehrift f. kliii. Medicin, Bd. 10.
194: SPECIFIC INFECTIOUS DISEASES.
rib or laceration of the lung, tuberculosis developed shortly after contu-
sion of the chest.
The production of general tuberculosis is sometimes favored by opera-
tion upon tuberculous lesions. Surgeons have long known that resection
of a strumous joint is occasionally followed by acute tuberculosis. The
question has been carefully studied by Wartmann,* who gives statistics of
837 resections. Of these, 225 ended fatally, 26 with acute tuberculosis,
the outbreak of which was directly associated with operation.
The acute miliary tuberculosis which, as Litten has shown, occasion-
ally follows the aspiration of the effusion in tuberculous pleurisy, may
come under this division.
The constant inhalation of impure air in occupations associated with
a very dusty atmosphere renders the lungs less capable of resisting infec-
tion. The pulmonary affection of stone-cutters and coal-miners, though
non-tuberculous at the outset and often a simple chronic interstitial pneu-
monia, is ultimately in a large proportion of the cases tuberculous. In
manufactories metallic seems more hurtful than mineral dust. Peterson f
quotes the incidence of pulmonary tuberculosis among the trades as fol-
lows : Glass- workers, 80 per cent ; needle-sharpeners, 70 ; file-cutters, 62 ;
and stone-cutters, 60. And, lastly, circumstances which temporarily lower
the nutrition, as the specific fevers render the tissues more susceptible. In
this way alone can we explain the frequent onset of tuberculosis after an
exhausting illness. Fevers, such as measles and whooping-cough, which
are associated with bronchial catarrh, are more prone than others to be
followed by tuberculosis. This is often only the blazing of a smoulder-
ing fire.
General Morbid Anatomy and Histology of Tuberculous
Lesions.
(1) Distribution of the Tubercles in the Body. — The organs of the
body are variously affected by tuberculosis. In adults, the lungs may be
regarded as the seat of election ; in children, the lymph-glands, bones, and
joints. In 1,000 autopsies there were 275 cases with tuberculous lesions.
With but two or three exceptions the lungs were affected. The distribu-
tion in the other organs was as follows : Pericardium, 7 ; peritonasum, 36 ;
brain, 31; spleen, 23; liver, 12; kidneys, 32; intestines, 65; heart, 4;
and generative organs, 8.
The tuberculosis which comes under the care of the surgeon has a dif-
ferent distribution, as shown by the following figures from the Wurzburg
clinic: Among 8,873 patients there were 1,287 tuberculous, with the
following distribution of lesions: Bones and joints, 1,037; lymph-glands,
196; skin and connective tissues, 77; mucous membranes, 10; genito-
urinary organs, 20.
* Deutsche Zoitschrift f. Chirurgie, Bd. 24.
f Medical News, 1885.
TUBERCULOSIS. 195
(2) The Changes produced by the Tubercle Bacilli.
(a) The Nodular Tubercle. — The body which wo term a " tubercle "
presents in its early formation notliing distinctive or 2)(^ouliar^ either in
its components or in their arrangeme7it. Identical structures are pro-
duced by otlier parasites, such as the actinomyces, and by the strongylus
in the lungs of sheep.
The researches of Baumgarten have enabled us to follow in detail all
the steps in the development of a tubercle.
These are : ( ) The multiplication of the fixed cells, especially those of
connective tissue and the endothelium of the capillaries, and the gradual
production from them of rounded, cuboidal, or polygonal bodies with
vesicular nuclei — tlie epithelioid cells — inside some of which the bacilli are
soon seen.
[i^) From the vessels of the infected focus, leucocytes migrate in
numbers and form the lymphoid cells which were thought to be so
characteristic of tubercle. They do not, however, undergo division.
(y) A reticulum of fibres is formed by the fibrillation and rarefaction
of the connective-tissue matrix. This is most apparent, as a rule, at the
margins of the growth.
(6) In some, but not all, tubercles giant cells are formed by an increase
in the protoplasm and in the nuclei of an individual cell, or possibly by
the fusion of several cells. The giant cells seem to be in inverse ratio to
the number and virulence of the bacilli. In lupus, joint tuberculosis,
and scrofulous glands, in which the bacilli are scanty, the giant cells are
numerous ; while in miliary tubercles and all lesions in which the bacilli
are abundant the giant cells are few in number.
The bacilli then cause, in the first place, a proliferation of the fixed
elements, with the production of epithelioid and giant cells; and, secondly,
an inflammatory reaction, associated with exudation of leucocytes. How
far the leucocytes attack and destroy the bacilli has not been definitely
settled — Metschnikoff claiming, Baumgarten denying, an active phago-
cytosis.
Once formed, a tubercle undergoes caseation and sclerosis.
Caseation. — At the central part of the growth, owing to the direct
action of the bacilli, a process of coagulation necrosis goes on in the cells,
which lose their outline, become irregular, no longer take stains, and are
finally converted into a homogeneous, structureless substance. Proceed-
ing from the centre outward, the tubercle may be gradually converted
into a yellowish-gray body, in which, however, the bacilli are still abundant.
No blood-vessels are found in them. Aggregated together these form the
cheesy masses so common in tuberculosis, which may undergo (a) soften-
ing ; {h) fibroid limitation (encapsulation) ; (6') calcification.
Sclerosis. — With the necrosis of the cell elements at the centre of the
tubercle, hyaline transformation proceeds, together with great increase in
the fibroid elements ; so that the tubercle is converted into a firm, hard
196 SPECIFIC INFECTIOUS DISEASES.
structure. Often the change is rather of a fibro-caseous nature ; but the
sclerosis predominates. In some situations, as the peritonaeum, this seems
to be the natural transformation of tubercle, and it is by no means rare in
the lungs.
In all tubercles two processes go on : the one — caseation — destructive
and dangerous ; and the other — sclerosis — conservative and healing. The
ultimate result in a given case depends upon the capabilities of the body
to restrict and limit the growth of the bacilli. There are tissue-soils in
which the bacilli are, in all probability, killed at once — the seed has fallen
by the wayside. There are others in which a lodgment is gained and
more or less damage done, but finally the day is with the conservative,
protecting forces — the seed lias fallen ujyon stony ground. Thirdly, there
are tissue-soils in which the bacilli grow luxuriantly, caseation and soft-
ening, not limitation and sclerosis, prevail, and the day is with the in-
vaders— the seed has fallen iifon good ground.
The action of the bacilli injected directly into the blood-vessels illus-
trates many points in the histology and pathology of tuberculosis. If into
the vein of a rabbit a pure culture of the bacilli is injected, the microbes
accumulate chiefly in the liver and spleen. The animal dies usually with-
in two weeks, and the organs apparently show no trace of tubercles.
Microscopically, in both spleen and liver the young tubercles in process of
formation are very numerous, and the process of karyokinesis is seen in
the liver-cells. After an injection of a more dilute culture, or one whose
virulence has been mitigated by age, instead of dying within a fortnight
the animal survives for five or six weeks, by which time the tubercles are
apparent in the spleen and liver, and often in the other organs.
{h) The Diffuse Infiltrated Tubercle. — This is most frequently seen in
the lungs. Only a great master like Virchow could have won the pro-
fession from a belief in the icnity of phthisis., which the genius of Laennec
had, on anatomical ground, announced. Here and there a teacher, as
Wilson Fox, protested, but the heresy prevailed, and we repeated the strik-
ing aphorism of Niemeyer, " The greatest evil which can happen to a con-
sumptive is that he should become tuberculous." It was thought that the
products of any simple inflammation might become caseous and that ordi-
nary catarrhal pneumonia terminated in phthisis. It was peculiarly fitting
that from Germany, in which the dualistic heresy arose, the truth of Laen-
nec's views should receive incontestable proof, in the demonstration by
Koch of the etiological unity of all the various processes known as tuber-
culous and scrofulous.
Infiltrated tubercle results from the fusion of many small foci of in-
fection— so small indeed that they may not be visible to the naked eye, but
which histologically are seen to be composed of scattered centres, sur-
rounded by areas in which the air-cells are filled with the products of exu-
dation and of the proliferation of the alveolar epithelium. Under the
influence of the bacilli, caseation takes place, usually in small groups of
TUBERCULOSIS. 107
lobules, occasionally in an entire lobe, or even the greater part of a lung.
In the early stage of the process, the tissue has a gray gelatinous appear-
ance, the gray infiltration of Laennec. The alveoli contain a sero-fibrinous
fluid with cells, and the septa are also infiltrated. These cells accumulate
and undergo coagulation necrosis, forming areas of caseation, the infiltra-
tion tuberculeuse jaune of Laennec, the scrofulous or cheesy pneumonia
of later writers. There may also be a diffuse infiltration and caseation
without any special foci, a wide-spread tuberculous pneumonia induced by
the bacilli.
After all, the two processes are identical. As Baumgarten states :
"there is no well-marked difference between miliary tubercle and chronic
caseous pneumonia. Speaking histologically, miliary tuberculosis is noth-
ing else than a chronic caseous miliary pneumonia, and chronic caseous
pneumonia is nothing but a tuberculosis of the lungs."
[c) Secondary Infiammatory Processes. — (1) The irritation of the
bacilli invariably produces an inflammation which may, as has been de-
scribed, be limited to exudation of leucocytes and serum, but may also be
much more extensive, and varies with varying conditions. We find, for
example, about the smaller tubercles in the lungs, pneumonia — either
catarrhal or fibrinous, proliferation of the connective-tissue elements in the
septa (which also become infiltrated with round cells), and changes in the
blood and lymph vessels.
(2) In processes of minor intensity the inflammation is of the slow
reactive nature, which results in the production of a cicatricial connective
tissue which limits and restricts the development of the tubercles and is
the essential conservative element in the disease. It is to be remembered
that in chronic pulmonary tuberculosis much of the fibroid tissue which is
present is not in any way associated with the action of the bacilli.
(3) Suppuration. Do the bacilli themselves induce suppuration? In
so-called cold tuberculous abscess the material is not histologically pus,
but a debris consisting of broken-down cells and cheesy material. It is
moreover sterile — that is, does not contain the usual pus organisms. The
products of the tubercle bacilli are probably able to induce suppuration,
as in joint and bone tuberculosis pus is frequently produced, although this
may be due to a mixed infection. Koch, it will be remembered, states
that the " tuberculin " is one of the best agents for the production of ex-
perimental suppuration. In tuberculosis of the lungs the suppuration is
largely the result of an infection with pus organisms.
II. Acute Tuberculosis.
The truly infective nature of tubercle is best shown in this affection,
which is characterized by an eruption of miliary tubercles in various parts
of the body. The clinical picture varies with the general or localized dis-
tribution of the growths. The tubercles are found upon the pleura and
198 SPECIFIC INFECTIOUS DISEASES.
peritonoeum ; in the lungs, liver, kidneys, lymph-glands, and spleen ; upon
the membranes of the brain, occasionally in the choroid coat of the eye,
and in the bone-marrow. They may be abundant in some organs and
scanty in others. Thus, in the meninges of the brain they may be thickly
set, while there are few or none in the abdominal viscera or in the lungs.
On t]ie other hand, the lungs may be stuffed with granulations while the
meninges of the brain are free. In other cases, again, the distribution is
uniform in all the viscera.
The etiology has been in part considered, and the only additional state-
ment necessary is that in a great majority of all cases it is an auto-infec-
tion^ arising from a pre-existing tuberculous focus, which may be latent
and unsuspected. The following are the most common sources of general
infection : Local disease of the lungs, which may be quite limited and un-
productive of symptoms ; tuberculous affection of the lymph-glands, par-
ticularly in children ; and tuberculosis of the bones and of the kidneys.
Of these sources perhaps the most common are the tracheal and bronchial
lymph-glands, which are so often the seat of local tuberculosis. Weigert
has shown that in many cases the infection results from the rupture of a
caseous pulmonary nodule into a vein, or of a caseous bronchial gland into
one of the pulmonary veins. A general infection may, as shown by Pon-
tic k, result from invasion of the thoracic duct by tubercles. With special
care the source of infection can usually be discovered at post-mortem
examination. The connection between tuberculous lymph-glands and
veins has often been demonstrated. In many instances it is impossible to
say what determines the sudden and violent onset of the disease. It would
seem sometimes as if general rather than local conditions influenced the
outbreak. After certain fevers, particularly measles and whooping-cough
in children — affections, it is true, which are associated with long-continued
bronchitis — miliary tuberculosis is not uncommon. The prostration and
constitutional weakness which follow protracted fevers frequently seem in
the adult a predisposing cause.
Clinical Forms. — For practical purposes the cases may be divided
into those with the symptoms of acute general infection without special
localization ; cases with marked pulmonary symptoms ; and cases with
cerebral or cerebrospinal symptoms.
Other forms have been recognized, but this division covers a large ma-
jority of the cases.
Taking any series of cases it will be found that the meningeal form of
acute tuberculosis exceeds in numbers the cases with general or marked
pulmonary symptoms.
1. General or Typhoid Form. — Symptoms. — The patient here presents
tlie symptoms of an infectious disease with few if any local symptoms.
The cases simulate and are frequently mistaken for typhoid fever. After
a period of failing health, with loss of appetite, the patient becomes
feverish and weak. Occasionally the disease sets in more abruptly, but in
TUBERCULOSIS. 199
many instances the anamnesis closely resembles that of typhoid fever.
Nose-bleeding, however, is rare. -The temperature increases, the pnlsc
becomes rapid and feeble, the tongue dry; delirium becomes marked and
the cheeks are flushed. The pulmonary symptoms may be very slight;
usually bronchitis exists, but not more severe than is common with typhoid
fever. The pulse is seldom dicrotic, but is rapid in proportion to the
pyrexia. Perhaps the most striking feature of the temperature is the
irregularity ; and if seen from the outset there is not the steady ascent
noted in typhoid fever. There is usually an evening rise to 103°, some-
times 104°, and a morning remission of from two to three degrees. Some-
times the pyrexia is intermittent, and the thermometer may register below
normal during the early morning hours. The inverse type of temperature,
in which the rise takes place in the morning, is held by some writers to be
more frequent in general tuberculosis than in other diseases. In rare in-
stances there may be little or no fever. On two occasions I have had a
patient admitted to my wards in a condition of profound debility, with a
history of illness of from three to four weeks' duration, with rapid pulse,
flushed cheeks, dry tongue, and very slight elevation in temperature, in
whom (post mortem) the condition proved to be general tuberculosis. In
one instance there was tolerably extensive disease at the right apex. Eein-
hold, from Baumler's clinic, has recently called attention to these afebrile
forms of acute tuberculosis. In nine of fifty-two cases there was no fever,
or only a transient rise.
In a considerable number of these cases the respirations are increased
in frequency, particularly in the early stage, and there may be signs of
diffuse bronchitis and slight cyanosis. Cheyne-Stokes breathing devel-
ops toward the close.
Active delirium is rare. More commonly there are torpor and dullness,
gradually deepening into coma, in which the patient dies. In some cases
the pulmonary symptoms become more marked ; in others, meningeal or
cerebral features develop.
Diagnosis. — The differential diagnosis between general miliary tuber-
culosis without local manifestations and typhoid fever is extremely diffi-
cult. A point of importance, to which reference has already been made,
is the irregularity of the temperature curve. The greater frequency of
the respirations and the tendency to slight cyanosis is much more com-
mon in tuberculosis. There are cases, however, of typhoid fever in which
the initial bronchitis is severe and may lead to dyspnoea and disturbed
oxygenation. The cough may be slight or absent. Diarrhoea is rare in
tuberculosis; the bowels are usually constipated; but diarrhoea may oc-
cur and persist for days. In certain cases the diagnosis has been compli-
cated still further by the occurrence of blood in the stools. Enlargement
of the spleen occurs in general tuberculosis, but is neither so early nor so
marked as in typhoid fever. In children, however, the enlargement may
be considerable. The urine may show traces of albumen, and unfortu-
11
200 SPECIFIC INFECTIOUS DISEASES.
nately Ehrlich's diazo-reaction, which is so constant in typhoid fever, is
also met with in general tuberculosis. The absence of the characteristic
roseola is an important feature. Occasionally in acute tuberculosis reddish
spots may develop and for a time cause difhculty, but they do not come
out in crops, and rarely have the characters of the true typhoid eruption.
Herpes is perhaps more common in tuberculosis. Toward the close, pete-
chias may appear on the skin, particularly about the wrists A rare event
is jaundice, due possibly to the eruption of tubercles in the liver.
In a few instances the presence of tubercle bacilli has been demon-
strated in the blood, which in doubtful cases should therefore be exam-
ined. The spleen has been punctured and cultivations made to determine
the presence or absence of the typhoid bacilli The eye-grounds should
be carefully examined for choroidal tubercles. Leucocytosis occurs in
acute tuberculosis, but not in typhoid fever.
2. Pulmonary Form. — SymjHoyns. — From the outset the pulmonary
symj^toms are marked The patient may have had a cough for months or
for years without much impairment of health, or he may be known to be
the subject of chronic pulmonary tuberculosis. In other instances, par-
ticularly in children, the disease follows measles and whooping-cough, and
is of a distinctly broncho-pneumonic type. The disease begins with the
symptoms of diffuse bronchitis. The cough is marked, the expectoration
muco-purulent, occasionally rusty. Haemoptysis has been noted in a few
instances. From the outset dyspnoea is a striking feature and may be out
of proportion to the intensity of the physical signs. In adults, the res-
pirations may be as hurried as in acute pneumonia, reaching from fifty to
sixty ; in children, as high as eighty or more. There is more or less cya-
nosis of the lips and finger-tips, and the cheeks are suffused. Apart from
emphysema and the later stages of severe pneumonia I know of no other
pulmonary condition in which the cyanosis is so marked. The physical
signs are those of bronchitis. There is rarely much alteration in the per-
cussion note. In children there may be defective resonance at the bases,
from scattered areas of broncho-pneumonia ; or, what is equally sugges-
tive, areas of hyper-resonance. Indeed, the percussion note, particularly
in the front of the chest, in some cases of miliary tuberculosis, is full and
clear, and it will be noted (post mortem) that the lungs are unusually
voluminous. This is probably the result of more or less wide-spread
acute empln'sema. On auscultation, the rales are either sibilant and
sonorous or small, fine, and crepitant. There may be fine crepitation
from the occurrence of tubercles on the pleura (Jiirgensen). In children
there may be high-pitched tubular breathing at the bases or toward the
root of the lung. Toward the close the rales may be larger and more
mucous. The temperature rises to 102° or 103°, and may present the in-
verse type. The pulse is rapid and feeble. In the very acute cases the
spleen is always enlarged. Tlie disease may prove fatal in ten or twelve
days, or may be protracted for weeks or even months.
TUBERCULOSIS. 201
Diagnosis. — The diagnosis of this form offers less difficulty and is
more frequently made. There is often a history of previous cough, or the
patient is known to be the subject of local disease of the lung, or of the
lymph-glands, or of the bones. In children these symptoms following
measles or whooping-cough indicate in the majority of cases acute miliary
tuberculosis, with or without broncho-pneumonia. Occasionally the spu-
tum contains tubercle bacilli.
The choroidal tubercle occurs in a limited number of cases and may
help the diagnosis. More important in an adult is the combination of
dyspnoea with cyanosis and the signs of a diffuse bronchitis. In some in-
stances the occurrence of cerebral symptoms at once give a clew to the
nature of the trouble.
3 Meningeal Form {Tuberculous Meningitis). — This affection, which is
also known as acute hydrocephalus or " water on the brain," is essentially
an acute tuberculosis in which the membranes of the brain, sometimes of
the cord, bear the brunt of the attack.
There are several special etiological factors in connection with this
form. It is much more common in children than in adults. It is rare
during the first year of life, more frequent between the second and the
fifth years. In a majority of the cases a focus of old tuberculous disease
will be found, commonly in the bronchial or mesenteric glands. In a few
instances the affection seems to be primary in the meninges. It is very
difficult, however, in an ordinary post-mortem to make an exhaustive
search, and the lesion may be in the bones, sometimes in the middle ear,
or in the genito-urinary organs. In those instances in which no primary
focus has been discovered it has been suggested that the bacilli reach the
meninges through the cribriform plate of the ethmoid from the upper
part of the nostrils, but this is not probable.
Morbid Anatomy. — Tuberculous meningitis presents a very character-
istic picture. The meninges at the base are most involved, hence the term
basilar meningitis. The parts about the optic chiasm, the Sylvian fissures,
and the interpeduncular space are affected. There may be only slight
turbidity and matting of the membranes, and a certain stickiness with
serous infiltration ; but more commonly there is a turbid exudate, fibrino-
purulent in character, which covers the structures at the base, surrounds
the nerves, extends out in the Sylvian fissures, and appears on the lateral,
rarely on the upper, surfaces of the hemispheres. The tubercles may be
very apparent, particularly in the Sylvian fissures, appearing as small,
whitish nodules on the membranes. They vary much in number and size,
and may be difficult to find. The amount of exudate bears no definite re-
lation to the abundance of tubercles. The arteries of the anterior and
posterior perforated spaces should be carefully withdrawn and searched,
as upon them nodular tubercles may be found when not present elsewhere.
In doubtful cases the middle cerebral arteries should be very carefully re-
moved, spread on a glass plate with a black background, and examined
202 SPECIFIC INFECTIOUS DISEASES.
with a low objective. The tubercles are then seen as nodular enlarge-
ments on the smaller arteries. The lateral ventricles are dilated (acute
hydrocephalus) and contain a turbid fluid ; the ependyma may be soft-
ened, and the septum lucidum and fornix are usually broken down. The
convolutions are often flattened and the sulci obliterated owing to the
increased intra-ventricular pressure. Histologically the tubercles are seen
to develop in the perivascular sheaths, producing circumscribed aggrega-
tions of lymphoid and epithelioid cells. The lumen of the vessel is nar-
rowed and thrombosis may result. The meninges are not alone involved,
but the contiguous cerebral substance is more or less o^dematous and infil-
trated with leucocytes, so that anatomically the condition is in reality a
meningo-ence2)haUtis.
There are instances in which the acute process is associated with
chronic meningeal tuberculosis ; cases which may for months present the
clinical picture of brain tumor.
Although in a majority of instances the process is cerebral, the spinal
meninges may also be involved, particularly those of the cervical cord.
There are cases indeed in which the symptoms are chiefly spinal. A sailor,
who had fallen on the deck three weeks before his death, was admitted to
the Montreal General Hospital. He presented signs of meningitis, chiefly
spinal, which were naturally attributed to traumatism. The post-mortem
showed absence of tubercles and lymph at the base of the brain, and an
extensive eruption of miliary tubercles with much turbid lymph over the
entire spinal meninges. There were small cheesy masses at the apices of
the lungs.
Sf/mpto?)is. — Tuberculous meningitis presents an extremely complex
clinical picture. It will be best to describe the form found in children.
Prodromal symptoms are common. The child may have been in fail-
ing health for some weeks, or may be convalescent from measles or whoop-
ing-cough. In many instances there is a history of a fall. The child
gets thin, is restless, peevish, irritable, loses its appetite, and the dispo-
sition may completely change. Symptoms pointing to the disease may
then set in, either quite suddenly with a convulsion, or more commonly
with headache, vomiting, and fever, three essential symptoms of the onset
which are rarely absent. The pain may be intense and agonizing. The
child puts its hand to its head and occasionally, when the pain becomes
worse, gives a short, sudden cry, the so-called hydrocephalic cry. Some-
times the child screams continuously until utterly exhausted. I saw in
West Philadelphia a case of basilar meningitis in a girl of thirteen, who
for three days, when not under the influence of a powerful sedative or of
chloroform, screamed at the top of her voice so as to be heard a square or
more away. The vomiting is without apparent cause, and is independent
of taking of food. Constipation is usually present. The fever is slight,
but gradually rises to 102° or 103°. The pulse is at first rapid, subse-
quently irregular and slow. The respirations are rarely altered. During
I
TUBERCULOSIS. 203
sleep the child is restless and disturbed. There may be twitcliings of the
muscles, or sudden startings; or the child may wake up from sleep in
great terror. In this early stage the pupils are usually contracted. These
are the chief symptoms of the initial stage, or, as it is termed, the stage of
irritation.
In the second period of the disease these irritative symptoms subside ;
vomiting is no longer marked, the abdomen becomes retracted, boat-
shaped or carinated. The bowels are obstinately constipated, the child no
longer complains of headache, but is dull and apathetic, and when roused
is more or less delirious. The head is often retracted and the child utters
an occasional cry. The pupils are dilated or irregular, and a squint may
develop. Sighing respiration is common. Convulsions may occur, or
rigidity of the muscles of one side or of one limb. The temperature is
variable, ranging from 100° to 102*5°. A blotchy erythema is not uncom-
mon on the skin. If the finger-nail is drawn across the skin of any region
a red line comes out quickly, the so-called tdclie cerebrate^ which, however,
has no diagnostic significance.
In the final period, or stage of paralysis^ the coma increases and the
child cannot be roused. Convulsions are not infrequent, and there are
spasmodic contractions of the muscles of the back and neck. Spasms
may occur in the limbs of one side. Optic neuritis and paralysis of the
ocular muscles may be present. The pupils become dilated, the eyelids
are only partially closed, and the eyeballs are rolled up so that the corneae
are only covered in part by the upper eyelid. Diarrhoea may develop, the
pulse becomes rapid, and the child may sink into a typhoid state with dry
tongue, low delirium, and involuntary passages of urine and faeces. The
temperature often becomes subnormal, sinking in rare instances to 93° or
94°. In some cases there is ante-mortem elevation of temperature, the
fever rising to 10G°. The entire duration of the disease is from a fort-
night to three or four weeks.
There are cases of tuberculous meningitis which pursue a more rapid
course. They set in with great violence, often in persons apparently in
good health, and may prove fatal within a few days. In these instances,
more commonly seen in adults, the convex surface of the brain is usually
involved. There are again instances which are essentially chronic and
display symptoms of a limited meningitis ; sometimes with pronounced
psychical symptoms, and sometimes with those of cerebral tumor.
There are certain features which call for special comment.
The irregularity and slowness of the pulse in the early and middle
stages of the disease are points upon which all authors agree. Toward the
close, as the heart's action becomes weaker, the pulsations are more fre-
quent. The temperature is usually elevated, but there are instances in
which it does not rise in the whole course of the disease much above 100°.
It may be extremely irregular, and the oscillations are often as much as
three or four degrees in the day. Toward the close the temperature may
204: SPECIFIC INFFX'TIOUS DISEASES.
sink to 95°, occasionally to 94°, or there may be hyperpyrexia. In a case
of Biiumler's the temperature rose before death to 43*7° C. (110-7° F.).
The ocular symptoms of the disease are of special importance. In the
early stages narrowing of the pupils is the rule. Toward the close, with
increase in the intra-cranial pressure, the pupils dilate and are irregular.
There niay be conjugate deviation of the eyes. Of ocular palsies the
third nerve is most frequently involved. The changes in the eye-grounds
are very important Neuritis is the most common. According to Gowers,
the disk at first becomes full colored and has hazy outlines, and the veins
are dilated. Swelling and striation become pronounced, but the neuritis is
rarely intense. Of twenty-six cases studied by Garlick, in six the con-
dition was of diagnostic value. The tubercles in the choroid are rare and
much less frequently seen during life than post-mortem figures would
indicate. Thus Litten found them (post mortem) in thirty-nine out of
fifty-two cases. They were present in only one of the twenty-six cases of
tuberculous meningitis examined by Garlick. I have never met them
clinically, and have only found two instances post mortem. Ileinzel exam-
ined with negative results forty-one cases.
Among the motor symptoms convulsions are most common, but there
are other changes which deserve special mention. A tetanic contraction
of one limb may persist for several days, or a cataleptic condition. Tremor
and athetoid movements are sometimes seen. The paralyses are either
hemiplegias or monoplegias. Hemiplegia may result from disturbance in
the cortical branches of the middle cerebral artery, occasionally from
softening in the internal capsule, due to involvement of the central
branches. Of monoplegias, that of the face is perhaps most common, and
if on the right side it may occur w^ith aphasia. In two of my cases in
adults aphasia developed. Brachial monoplegia may be associated with it.
In the more chronic cases the symptoms persist for months, and there may
be a characteristic Jacksonian epilepsy when the tubercles involve the
meninges of the motor cortex.
The prognosis in this form of meningitis is always most serious. I
have neither seen a case which I regarded as tuberculous recover, nor
have I seen post-mortem evidence of past disease of this nature. Cases of
recovery have been reported by reliable authorities, but they are extremely
rare, and there is always a reasonable doubt as to the correctness of the
diagnosis. The differential features will be considered in connection with
acute meningitis.
III. TrnERCULOSis of the Lym pit-glands {Scrofula).
Scrofula is tubercle, as it has been shown that the bacillus of Koch is
the essential element. It is not yet definitely settled whether the virus
which produces the chronic adenitis or scrofula differs from that which
produces tuberculosis in other parts, or whether it is the local conditions
TUBERCULOSIS, 205
in the glands which account for the slow development and milder course.
The experiments of Arloing would indicate that the virus was attenuated
or milder, for he has shown that the caseous material of a lymph-glaud
killed guinea-pigs, while rabbits escaped. The guinea-pig, as is well
known, is the more susceptible animal of the two. The observations of
Lingard are still more conclusive, as showing a variation in the virulence
of the tubercle bacillus. Guinea-pigs inoculated with ordinary tubercle
showed lymphatic infection within the first week, and the animals died
within three months ; infected with material from scrofulous glands, the
lymphatic enlargement did not appear until the second or third week, and
the animals survived for six or seven months. He showed, moreover, that
the virulence of the infection obtained from the scrofulous glands in-
creased in intensity by passing through a series of guinea-pigs. Eve's ex-
periments show that scrofulous material invariably produces tuberculosis
in guinea-pigs and very often in rabbits.
Tuberculous adenitis is met with at all ages. It is more common in
children than in adults, but it is not infrequent in the middle period of
life, and may occur in old age.
The tubercle bacillus is ubiquitous. All are exposed to infection, and
upon the local conditions, whether favorable or unfavorable, depend the
fate of those organisms which find lodgment in our bodies. It is possible,
of course, that tuberculous adenitis may be congenital, but such instances
must be extremely rare. A special predisposing factor in lymphatic tuber-
culosis is catarrhal inflammation of the mucous membranes, which in itself
excites slight adenitis of the neighboring glands. In a child with con-
stantly recurring naso-pharyngeal catarrh, the bacilli which lodge on the
mucous membranes find in all probability the gateways less strictly
guarded and are taken up by the lymphatics and passed to the nearest
glands In conditions of health the local resistance, or, as some would
put it, the phagocytes, would be active enough to deal with the invaders,
but the irritation of a chronic catarrh weakens the resistance of the lymph-
tissue and the bacilli are enabled to develop and gradually to change a
simple into a tuberculous adenitis. The frequent association of tubercu-
lous adenitis of the bronchial glands with whooping-cough and with
measles, and the frequent development of tubercle in the mesenteric
glands in children with intestinal catarrh, find in this way a rational ex-
planation. After all, as Virchow pointed out, an increased vulnerability
of the tissue, however brought about, is the important factor in the disease.
The following are some of the features of interest in tuberculous ade-
nitis :
(a) The local character of the disease ; thus, the glands of the neck, or
at the bifurcation of the bronchi, or those of the mesentery, may be alone
involved.
(/y) The tendency to spontaneous healing. In a large proportion of
the cases the battle which ensues between the bacilli and the tissue-cells is
206 SPECIFIC INFECTIOUS DISEASES.
long; but the latter are finally successful, and we find in the calcified
remnants in the bronchial and mesenteric lymph-glands evidences of vic-
tory. Too often in the broncliial glands a truce only is declared and hos-
tilities may break out afresh in the form of an acute tuberculosis.
(c) The tendency of tuberculous adenitis to pass on to suppuration.
The frequency with which, particularly in the glands of the neck, we find
the tuberculous processes associated with pus is a special feature of this
form of adenitis. In nearly all instances the pus is sterile. Whether the
suppuration is excited by the bacilli or by their products, or whether it is
the result of a mixed infection with pus organisms, which are subse-
quently destroyed, has not been settled.
(d) The existence of an unhealed focus of tuberculous adenitis is a
constant menace to the organism. It is safe to say that in three fourths
of tlie instances of acute tuberculosis the infection is derived from this
source. On the other hand, it has been urged that scrofula in childhood
gives a sort of protection against tuberculosis in adult life. We certainly
do meet with many persons of exceptional bodily vigor who in childhood
had enlarged glands, but the evidence which Marfan * brings forward in
support of this view is not conclusive.
Clinical Forms. — 1. General Tuberculous Lymphadenitis. — In ex-
ceptional instances we find diffuse tuberculosis of nearly all the lymph-
glands of the body with little or no involvement of other parts. The most
extreme cases of it which I have seen have been in negro patients. Two
well-marked cases occurred at the Philadelphia Hospital. In one, a
woman, aged thirty-four, was admitted April 4th, with enlarged glands in
the right side of the neck and irregular fever. Tlie chart from April,
1888, until March, 1889, showed persistent fever, ranging from 101° to
103°, occasionally rising to 104°. On December IGth the glands on the
right side of the neck were removed. After an attack of erysipelas, on
February 17th, she gradually sank and died March 5th. The lungs pre-
sented only one or two puckered spots at the apices. The bronchial,
retro-peritoneal, and mesenteric glands were greatly enlarged and caseous.
No intestinal, uterine, or bone disease. The continuous high fever in
this case depended apparently upon the tuberculous adenitis, which was
much more extensive than was supposed during life. In these instances
the enlargement is most marked in the retro-peritoneal, bronchial, and
mesenteric glands, but may be also present in the groups of external
glands. Occurring acutely, it presents a picture resembling Ilodgkin's
disease. In a case which died in the Montreal General Hospital this
diagnosis was made. The cervical and axillary glands were enormously
enlarged, and death was caused by infiltration of the larynx.
2. Local Tuberculous Adenitis. — (a) Cervical — This is the most com-
mon form met with in children. It is seen particularly among the poor
* Archives generales, 1886.
TUBERCULOSIS. 207
and those who live continuously in the impure atmosphere of badly venti-
lated lodgings. Children in foundling hospitals and asylums are specially
prone to the disease. In this country it is most common in the negro
race. As already stated, it is often met with in catarrh of the nose and
throat, or chronic enlargement of the tonsils ; or the child may have
had eczema of the scalp or a purulent otitis.
The submaxillary glands are first involved, and are popularly spoken
of as enlarged kernels. They are usually larger on one side than on the
other. As they increase in size, the individual tumors can be felt ; the
surface is smooth and the consistence firm. They may remain isolated,
but more commonly they form large, knotted masses, over which the
skin is, as a rule, freely movable. In many cases the skin ultimately be-
comes adherent, and inflammation and suppuration occur. An abscess
points and, unless opened, bursts, leaving a sinus which heals slowly.
The disease is frequently associated with coryza, with eczema of the scalp,
ear, or lips, and with conjunctivitis or keratitis. When the glands are
large and growing actively, there is fever. The subjects are usually anae-
mic, particularly if suppuration has occurred. The progress of this form
of adenitis is slow and tedious. Death, however, rarely follows, and many
aggravated cases in children ultimately get well. Not only the submaxil-
lary group, but the glands above the clavicle and in the posterior cervical
triangle, may be involved. In other instances the cervical and axillary
glands are involved together, forming a continuous chain which extends
beneath the clavicle and the pectoral muscle. With them the bronchial
glands may also be enlarged and caseous. Not infrequently the enlarge-
ment of the supraclavicular and axillary group of glands on one side
precedes the development of a tuberculous pleurisy or of pulmonary
tuberculosis.
{h) Bronchial. — The mediastinal lymph-glands constitute filters in
which lodge the various foreign particles which escape the normal phago-
cytes of bronchi and lungs. Among these foreign particles, and probably
attached to them, tubercle bacilli are not uncommon, and we find tuber-
cles and caseous matter with great frequency in the mediastinal glands,
particularly those about the bronchi. It is stated that this process is
always secondary to a focus, however small, in the lungs, but my experi-
ence does not bear out such a statement. As already mentioned, Nortli-
rup found them involved in every one of a hundred and twenty-seven
cases at the New York Foundling Hospital. This tuberculous adenitis
may, in the bronchial glands, attain the dimensions of a tumor of large
size. But even when this occurs there may be no pressure symptoms.
In children the bronchial adenitis is apt to be associated with suppuration.
A more serious danger in tuberculous disease of the bronchial glands
is systemic infection, which takes place through the vessels. Local in-
fection of th(! lungs may also occur. In the tuberculous broncho-pneu-
monia of children it is usual to find the bronchial glands enormously en-
208 SPECIFIC INFECTIOUS DISEASES.
larged, passing deeply into the liilus, adjoining, and in some instances
even merging with, areas of caseation of the pulmonary tissue itself.
There is a special danger of infection of the pericardium by tubercu-
lous lymph-glands in the anterior mediastinum.
(c) Mesenteric ; Tahes mesenterica. — In this affection, the abdominal
scrofula of old writers, the glands of the mesentery and retro-peritonaeum
become enlarged and caseate ; more rarely they suppurate or calcify. A
slight tuberculous adenitis is extremely common in children, and is often
accidentally found (post mortem) when the children have died of other
diseases. It may be a primary lesion associated with intestinal catarrh, or
it may be secondary to tuberculous disease of the intestines.
The primary cases are very common in children, as may be gathered
from Woodhead's figures. The general involvement of the glands inter-
feres seriously with nutrition, and the patients are puny, wasted, and anae-
mic. The abdomen is enlarged and tympanitic ; diarrhoea is a constant
feature ; the stools are thin and offensive. There is moderate fever, but
the general wasting and debility are the most characteristic features. The
enlarged glands cannot often be felt, owing to the distended condition of
the bowels. These cases are often spoken of as consumption of the
bowels, but in a majority of them the intestines do not present tuber-
culous lesions. In a considerable number of the cases of tabes mesen-
terica the peritonaeum is also involved, and in such the abdomen is large
and hard, and nodules may be felt. The condition is one to which the
French have given the name carreau.
In adults tuberculous disease of the mesenteric glands may occur as a
primary affection, or in association with pulmonary disease. Gairdner *
gives a remarkable instance of the kind in a man aged twenty-one. In-
stances of this sort are not uncommon in the literature. Large tumors
may exist without tuberculous disease in the intestines or in any other
parts.
The diagnosis of local and general tuberculous adenitis from lym-
phadenoma will be subsequently considered.
IV. Pulmonary Tuberculosis {Phthisis, Consumjjtion).
Three clinical groups may be conveniently recognized: (1) tuberculo-
p?ie2imonic jjhthisis — acute phthisis; (2) chronic ulcerative j^hthi sis ; and
(3) fibroid phthisis.
According to the mode of infection there are two distinct types of
lesions :
{a) When the bacilli reach the lungs through the blood-vessels, the
primary lesion is usually in the tissues of the alveolar walls, in the capil-
lary vessels, the epithelium of the air-cells, and in tlie connective-tissue
* Lectures to Practitioners, Gairdner and Coats, 1888.
TUBERCULOSIS. 209
framework of the septa. The process of cell division proceeds as already
described in the general histology of tubercle. The irritation of the
bacilli produces, within a few days, the small, gray miliary nodules, involv-
ing several alveoli and consisting largely of round, cuboidal, uninuclear
epithelioid cells. Depending upon the number of bacilli which reach the
lung in this way, either a localized or a general tuberculosis is excited.
The tubercles may be uniformly scattered through both lungs and form
a part of a general miliary tuberculosis, or they may be confined to the
lungs, or even in great part to one lung. The changes which the tuber-
cles undergo have already been referred to. The further changes may be :
(1) Arrest of the process of cell division, gradual sclerosis of the tubercle,
and ultimately complete fibroid transformation. (2) Caseation of the
centre of the tubercle, extension at the periphery by proliferation of the
epithelioid and lymphoid cells, so that the individual tubercles or small
groups become confluent and form diffuse areas which undergo caseation
and softening. (3) Occasionally as a result of intense infection of a
localized region through the blood-vessels the tubercles are thickly set.
The intervening tissue becomes acutely inflamed, the air-cells are filled
with the products of a desquamative pneumonia, and many lobules are
involved.
{b) When the bacilli reach the lung through the bronchi — inhalation
tuberculosis — the picture differs. The smaller bronchi and bronchioles
are more extensively affected ; the process is not confined to single groups
of alveoli, but has a more lobular arrangement, and the tuberculous masses
from the outset are larger, more diffuse, and may in some cases involve
an entire lobe or the greater part of a lung. . It is in this mode of infection
that we see the characteristic peri-bronchial granulations and the areas
of the so-called nodular broncho-pneumonia. These broncho-pneumonic
areas, with on the one hand caseation, ulceration, and cavity formation,
and on the other sclerosis and limitation, make up the essential ele-
ments in the anatomical picture of tuberculous phthisis.
1. Acute Pneumonic Phthisis.
This form, known also by the name of galloping consumption, is met
with both in children and adults. In the former many of the cases are
mistaken for simple broncho-pneumonia.
Two types may be recognized, t\\Q pneumonic and hroncho-2)neumonic.
(a) In the pneumonic form one lobe may be involved, or in some in-
stances an entire lung. The organ is heavy, the affected portion airless,
the pleura usually covered with thin exudation, and on section the picture
resembles closely that of ordinary hepatization. The following is an extract
from the post-mortem report of a case in which death occurred twenty-nine
days after the onset of the illness, having all the characters of an acute
pneumonia : " Left lung weighs 1,500 grammes (double the weight of the
210 SPECIFIC INFECTIOUS DISEASES.
other organ) and is heavy and airless, crepitant only at the anterior mar-
gins Section shows a small cavity the size of a walnut at the apex, about
wliich are scattered tubercles in a consolidated tissue. The greater part
of tlie lung presents a grayish-white appearance due to the aggregation
of tubercles which in some places have a continuous, uniform appearance,
in others are surrounded by an injected and consolidated lung-tissue.
Toward the margins of the lower lobe strands of this firm reddish tissue
separate anaemic, dry areas. There are in the right lung three or four
small groups of tubercles but no caseous masses. The bronchial glands
are not tuberculous." Here the intense local infection was due to the
small focus at the apex of the lung, probably an aspiration process.
Only the most careful inspection may reveal the presence of miliary
tubercles, or the attention may be arrested by the detection of tubercles in
the other lung or in the bronchial glands. The process may involve only
one lobe. There may be older areas which are of a peculiarly yellowish-
white color and distinctly caseous. The most remarkable picture is pre-
sented by cases of this kind in which the disease lasts for some months.
A lobe or an entire lung may be enlarged, firm, airless throughout, and
converted into a dry, yellowish-white, cheesy substance. Cases are met
with in which the entire lung from apex to base is in this condition, with
perhaps only a small, narrow area of air-containing tissue on the margin.
More commonly, if the case has lasted for two or three months, rapid
softening has taken place at the apex. The following brief extract gives
the actual condition of the lung in a case in which death occurred in the
eleventh week : " Left lung is solid and heavy, weighing 1,490 grammes,
and is nowhere crepitant. The upper third of the upper lobe is occupied
by a cavity, containing blood and pus, the walls of which are formed by
ragged caseous masses. The rest of the lung is firm and solid, and on
section presents a uniform opaque white color. The surface is dry, and
all parts present the same cheesy appearance."
Symptoms. — The attack sets in abruptly with a chill, usually in an
individual who has enjoyed good health, although in many cases the onset
has been preceded by exposure to cold, or there have been debilitating
circumstances. The temperature rises rapidly after the chill, there are
pain in the side, and cough, with at first mucoid, subsequently rusty-
colored expectoration. The dyspna}a may become extreme and the
patient may have suffocative attacks. The physical examination shows
involvement of one lobe or of one lung, wuth signs of consolidation, dul-
ness, increased fremitus, at first feeble or suppressed vesicular murmur,
and subsequently well-marked bronchial breathing. The upper or lower
lobe may be involved, or in some cases the entire lung.
At this time, as a rule, no suspicion enters the mind of the practitioner
tliat the case is anything but one of frank lobar pneumonia. Occasion-
ally there may be suspicious circumstances in the history of the patient
or in his family; but, as a rule, no stress is laid upon them in comparison
TUBERCULOSIS. 211
with the intense and characteristic mode of onset. Between the eightli
and tenth day, instead of the expected crisis, the condition becomes
aggravated, the temperature is irregular, and tlie pulse more rapid.
There may be sweating, and the expectoration becomes muco-purulent.
Even in the second or third week, with the persistence of these symptoms,
the physician tries to console himself with the idea that the case is one of
unresolved pneumonia, and that all will yet be well. Gradually, however,
the severity of the symptoms, the presence of physical signs indicating
softening, the existence of elastic tissue and tubercle bacilli in the sputa
present the mournful proofs that the case is one of acute pneumonic
phthisis. Death may occur before softening takes place, even in the
second or third week. In other cases there is extensive destruction at
the apex, with rapid formation of cavity, and the case may drag on for
two or three months.
Diagnosis. — It is by no means widely recognized in the profession
that there is a form of acute phthisis which may closely simulate ordinary
pneumonia. Waters, of Liverpool, gave an admirable description of these
cases, and called attention to the difficulty in distinguishing them from
ordinary pneumonia. Certainly the mode of onset affords no criterion
whatever. A healthy, robust-looking young Irishman, a cab- driver, who
had been kept waiting on a cold, blustering night until three in the morn-
ing, was seized the next afternoon with a violent chill, and the following
day was admitted to my wards at the University Hospital, Philadelphia.
He was made the subject of a clinical lecture on the fifth day, when there
was absent no single feature in history, symptoms, or physical signs of
acute lobar pneumonia of the right upper lobe. It was not until ten days
later, when bacilli were found in his expectoration, that we were made
aware of the true nature of the case. I know of no criterion by which
cases of this kind can be distinguished in the early stage. The tubercle
bacilli are not present at first. A point to which Traube called attention,
and which is also referred to as important by Herard and Cornil, is the
absence of breath-sounds in the consolidated region ; but this, I am sure,
does not hold good in all cases. The tubular breathing may be intense
and marked as early as the fourth day ; and again, how common it is to
have, as one of the earliest and most suggestive symptoms of lobar pneu-
monia, suppression or enfeeblement of the vesicular murmur ! In many
cases, however, there are suspicious circumstances in the onset ; the pa-
tient has been in bad health, or may have had previous pulmonary trouble,
or there are recurring chills. Careful examination of the sputa and a
study of the physical signs from day to day can alone determine the true
nature of the case. A point of some moment is the character of the fever,
which in true pneumonia is more continuous, particularly in severe cases,
whereas in this form of tuberculosis remissions of 1'5° or 2° are not in-
frequent.
(b) Acute tuberculous hronclio-pneumonia is more common, particu-
212 SPECIFIC INFECTIOUS DISEASES.
larly in children, and forms a majority of the cases of phthisis florida or
"galloping consumption." It is an acute caseous broncho-pneumonia,
starting in the smaller tubes, which become blocked with a cheesy sub-
stance, while the air-cells of the lobule are filled with the products of a
catarrhal pneumonia. In the early stage the areas have a grayish-red, later
an opaque- white, caseous appearance. By the fusion of contiguous masses
an entire lobe may be rendered nearly solid, but there can usually be seen
between the groups areas of crepitant air tissue. This is not an uncom-
mon picture in the acute phthisis of adults, but it is still more frequent in
children. The following is an extract from the post-mortem of a case on
a child aged four months, which died in the sixth week of illness : " The
upper lobe of the right lung is scarcely anywhere crepitant except at the
anterior edge. The middle and lower lobes are heavy and slightly crepi-
tant ; the visceral pleura is beset with tubercles which have grown into it
from the lung. On section the right upper lobe is occupied with caseous
masses from five to twelve millimetres in diameter, separated from each
other by an intervening tissue of a deep-red color. The bronchi are filled
with cheesy substance The middle and lower lobes are stuffed with tuber-
cles, many of which are becoming caseous. Toward the diaphragmatic sur-
face of the lower lobe there is a small cavity, the size of a marble. The left
lung is more crepitant and uniformly studded with tubercles of all sizes,
some as large as peas. There is an acute tuberculous bronchitis in the
smaller and larger branches, and extending into the trachea. The bron-
chial glands are very large, and one contains a tuberculous abscess."
In children the enlarged bronchial glands usually surround the root of
the lung, and even pass deeply into the substance, and the lobules are
often involved by direct contact.*
In other cases the caseous broncho-pneumonia involves groups of alveoli
or lobules in different portions of the lungs, more commonly at both apices,
forming areas from one to three centimetres in diameter. The size of the
mass depends largely upon that of the bronchus involved. There are cases
which probably should come in this category, in which, with a history of
an acute illness of from four to eight weeks, the lungs are extensively stud-
ded with large gray tubercles, ranging in size from five to ten millimetres.
In some instances there are cheesy masses the size of a cherry. All of
these are grayish-white in color, distinctly cheesy, and. between the adja-
cent ones, particularly in the lower lobe, there may be recent pneumonia,
or the condition of lung which has been termed splenization. In a case of
this kind at the Philadeli^liia Hospital death took place about the eighth
week from the abrupt onset of the illness with haemorrhage. There were
no extensive areas of consolidation, but the cheesy nodules were uniformly
scattered throughout both lungs. Xo softening had taken place.
* Vide the drawings illustrating Northrup's article ; New York Medical Journal,
February 21, 181)1.
TUBERCULOSIS. 213
Symptoms. — Tlie symptoms of acute broncho-pneumonic phthisis
are very varijible. In adults the disease may attack persons in. ^ood liealth,
but who are overworked or " run down " from any cause, licemorrhage
initiates the attack in a few cases.- There may be repeated chills ; the
temperature is high, the pulse rapid, and the respirations are increased.
The loss of flesh and strength is very striking.
The physical signs may at first be uncertain and indefinite, but finally
there are areas of impaired resonance, usually at the apices ; the breath-
sounds are harsh and tubular, with numerous rales. The sputa may early
show elastic tissue and tubercle bacilli. In the acute cases, within three
weeks, the patient may be in a marked typhoid state, with delirium, dry
tongue, and high fever. Death may occur within three weeks. In other
cases the onset is severe, with high fever, rapid loss of flesh and strength,
and signs of extensive unilateral or bilateral disease. Softening takes
place ; there are sweats, chills, and progressive emaciation, and all the
features of phthisis florida. Six or eight weeks or later the patient may
begin to improve, the fever lessens, the general symptoms mitigate, and a
case which looked as if it would certainly terminate fatally within a few
weeks drags on and becomes chronic.
In children the disease most commonly follows the infectious diseases,
particularly measles and whooping-cough.* The profession is gradually
recognizing the fact that a majority of all such cases are tuberculous.
At least three groups of these cases of tuberculous broncho-pneumonia
may be recognized. In the first the child is taken ill suddenly while
teething or during convalescence from fever; the temperature rises rapidly,
the cough is severe, and there may be signs of consolidation at one or both
apices with rales. Death may occur within a few days, and the lung shows
areas of broncho-pneumonia, with perhaps here and there scattered opaque
grayish-yellow nodules. Macroscopically the affection does not look tuber-
culous, but histologically miliary granulations and bacilli may be found. f
Tubercles are usually present in the bronchial glands, but the appearance
of the broncho-pneumonia may be exceedingly deceptive, and it may re-
quire careful microscopical examination to determine its tuberculous char-
acter. The second group is represented by the case of the child previously
quoted, which died at the sixth week with the ordinary symptoms of severe
broncho-pneumonia. And the third group is that in which, during the
convalescence from an infectious disease, the child is taken ill with fever,
cough, and shortness of breath. The severity of the symptoms miti-
gates within the first fortnight; but there is loss of flesh, the general
condition is bad, and the physical examination shows the presence of
scattered rales throughout the lungs, and here and there areas of de-
fective resonance. The child has sweats, the fever becomes hectic in
* "Tussis convulsiva vestibulum tabis" (Willis),
f Coriiil and Babes, Les Bacteries, tome ii, IbUO.
214: SPECIFIC INFECTIOUS DISEASES.
character, and in many cases the clinical picture gradually develops
into that of chronic phthisis.
2. Chronic Ulcerative Phthisis.
Under this heading may be grouped the great majority of cases of pul-
monary tuberculosis, in which the lesions proceed to ulceration and soften-
ing, and ultimately produce the well-known picture of chronic phthisis.
At first a strictly tuberculous affection, it ultimately becomes, in a majority
of cases, a mixed disease, many of the most prominent symptoms of which
are due to septic infection from purulent foci and cavities.
Morbid Anatomy. — Inspection of the lungs in a case of chronic
phthisis shows a remarkable variety of lesions, comprising nodular tuber-
cles, diffuse tuberculous infiltration, caseous masses, pneumonic areas,
cavities of various size, with changes in the pleura, bronchi, and bronchial
glands.
1. The Distribution of the Lesions. — For years it has been recognized
that the most advanced lesions are at the apices, and that the disease
progresses downward, usually more rapidly in one of the lungs. This
general statement, which has passed current in the text-books ever since
the masterly description of Laennec, has recently been carefully elabo-
rated by Kingston Fowler, who finds that the disease in its onward pro-
gress through the lungs follows, in a majority of the cases, distinct routes.
In the upper lobe the primary lesion is not, as a rule, at the extreme
apex, but from an inch to an inch and a half below the summit of the
lung, and nearer to the posterior and external borders. The lesion here
tends to spread downward, probably from inhalation of the virus, and
this accounts for the frequent circumstance that examination behind, in
the supraspinus fossa, will give indications of disease before any evidences
exist at the apex in front. Anteriorly this initial focus corresponds to a
spot just below the centre of the clavicle, and the direction of extension
in front is along the anterior aspect of the upper lobe, along a line run-
ning about an inch and a half from the inner ends of the first, second,
and third interspaces. A second less common site of the primary lesion
in the apex "corresponds on the chest wall with the first and second,
interspaces below the outer third of the clavicle." The extension is down-
ward, so that the outer part of the upper lobe is chiefly involved.
In the middle lobe of the right lung the affection usually follows the
upper lobe on the same side. In the involvement of the lower lobe the
first secondary infiltration is about an inch to an inch and a half below
the posterior extremity of its apex, and corresponds on the chest wall to a
spot opposite the fifth dorsal spine. This involvement is of the greatest
importance clinically, as " in the great majority of cases, when the physi-
cal signs of tlie disease at the apex are sufficiently definite to allow of tlie
diagnosis of phthisis being made, the lower lobe is already atfected." Ex-
TUBERCULOSIS. 215
amination, therefore, should be made carefully of this posterior apex in
all suspicious cases. In this situation the lesion spreads downward and
laterally along the line of the interlobular septa, a line which is marked
by the vertebral border of the scapula, when the hand is placed on the
opposite scapula and the elbow raised above the level of the shoulder.
Once present in an apex, the disease usually extends in time to the oppo-
site upper lobe ; but not, as a rule, until the apex of the lower lobe of the
lung first affected has been attacked.
Of 427 cases above mentioned, the right apex was involved in 172, the
left in 130, both in 111.
Lesions of the base may be primary, though this is rare. Percy Kidd
makes the proportion of basic to apicic phthisis one to five hundred, a
smaller number than existed in my series. In very chronic cases there
may be arrested lesions at the apex and more recent lesions at the base.
2. Summary of the Lesions in Chronic Ulcerative Phthisis.— («) Mili-
ary Tubercles. — These may not be evident on microscopical examination,
or there may be a few colonies, " the secondary crop " of Laennec, about
the caseous areas. In other instances, with old lesions at the apex, there
are, throughout the lower lobes, scattered groups of miliary tubercles
which have undergone fibroid and pigmentary changes. Sometimes, in
cases with cavity formation at the apex, the greater part of the lower lobes
present many groups of firm, sclerotic, miliary tubercles, which may in-
deed form the distinguishing anatomical feature — a chronic miliary tuber-
culosis.
{b) Tuberculous Broncho-pneumonia. — In a large proportion of the
cases of chronic phthisis the terminal bronchiole is the point of origin of
the process, consequently we find the smaller bronchi and their alveolar
territories blocked with the accumulated products of inflammation in all
stages of caseation. At an early period a cross-section of an area of tuber-
culous broncho-pneumonia gives the most characteristic appearance. The
central bronchiole is seen as a small orifice, or it is plugged with cheesy con-
tents, while surrounding it is a caseous nodule, the so-called peribronchial
tubercle. The longitudinal section has a somewhat dendritic or foliaceous
appearance. The condition of the picture depends much upon the slow-
ness or rapidity with which the process has advanced. The following
changes may occur :
Ulceration. — AVhen the caseation takes place rapidly or ulceration
occurs in the bronchial wall, the mass may break down and form a small
cavity.
Sclerosis. — In other instances the process is more chronic. Fibroid
changes gradually produce a sclerosis of the affected area, a condition
which is sometimes called cirrhosis nodosa tuberculosa. The sclerosis may
be confined to the margin of the mass, forming a limiting capsule, within
which is a uniform, firm, cheesy substance, in which lime salts are often
deposited. This represents the healing of one of these areas of caseous
15
216 SPECIFIC INFECTIOUS DISEASES.
bronclio-pneumonia. It is only, liowever, when complete fibroid trans-
formation or calcification has occurred that we can really speak of healing.
In many instances the colonies of miliary tubercles about these masses
show that the virus is still active in them. Subsequently, in ulcerative
processes, these calcareous bodies — lung-stones, as they are sometimes
called — m.ay be expectorated.
(c) Pneumonia. — An important though secondary place is occupied
by inflammation of the alveoli surrounding the tubercles, which become
filled with epithelioid cells. The consolidation may extend for some dis-
tance about the tuberculous foci and unite them into areas of uniform con-
solidation. Although in some instances this inflammatory process may be
simple, in others it is undoubtedly specific. It is excited by the tubercle
bacilli and is a manifestation of their action. It may present a very varied
appearance ; in some instances resembling closely ordinary red hepatiza-
tion, in others more homogeneous and infiltrated, the so-called infiltratio7i
tuherculeuse of Laennec. In other cases the contents of the alveoli un-
dergo fatty degeneration, and appear on the cut surface as opaque white
or yellowish-white bodies. In early phthisis much of the consolidation is
due to this pneumonic infiltration, which may surround for some distance
the smaller tuberculous foci.
{d) Cavities. — A vomica is a cavity in the lung tissue, produced by
necrosis and ulceration. It differs materially from the bronchiectatic
form. The process usually begins in the wall of the bronchus in a tuber-
culous area. Dilatation is produced by retained secretion, and necrosis and
ulceration of the wall occur with gradual destruction of the contiguous
tissues. By extension of the necrosis and ulceration the cavity increases,
contiguous ones unite, and in an affected region there may be a series of
small excavations communicating with a bronchus. In nearly all instances
the process extends from the bronchi, though it is possible for necrosis
and softening to take place in the centre of a caseous area without pri-
mary involvement of the bronchial wall. Three forms of cavities may be
recognized :
The fresli ulcerative^ seen in acute phthisis, in which there is no
limiting membrane, but the walls are made up of softened, necrotic, and
caseous masses. Small vomicae of this sort, situated just beneath the
pleura, may rupture and cause pneumothorax. In cases of acute tuber-
culo-pneumonic phthisis they may be large, occupying the greater portion
of the upper lobe. In the chronic ulcerative phthisis, cavities of this sort
are invariably present in those portions of the lung in whicli the disease is
advancing. At the apex there may be a large old cavity with well-defined
walls, while at the anterior margin of the upper lobes, or in the apices of
the lower lobe, there are recent ulcerating cavities communicating with
the bronchi.
Cavities with well-defined walls. — A majority of the cavities in the
chronic form of phthisis have a well-defined limiting membrane, the
TUBERCULOSIS. 217
inner surface of whicli constantly produces pus. The walls arc crossed
by trabeculae which represent remnants of bronchi and blood-vessels.
Even the vomicae with the well-defined walls extend gradually by a slow
necrosis and destruction of the contiguous lung tissue. The contents are
usually purulent, similar in character to the grayish nummular sputa
coughed up by phthisical patients. Not infrequently the membrane is
vascular or it may be haemorrhagic. Occasionally, when gangrene has
occurred in the wall, the contents are horribly foetid. These cavities may
occupy the greater portion of the apex, forming an irregular series which
communicate with each other and with the bronchi, or the entire upper
lobe except the anterior margin may be excavated, forming a thin-walled
cavity. In rare instances the process has proceeded to total excavation of
the lung, not a remnant of which remains, except perhaps a narrow strip
at the anterior margin. In a case of this kind, in a young girl, the cavity
held forty fluidounces.
Quiescent Cavities. — When quite small and surrounded by dense cica-
tricial tissue communicating with the bronchi they form the cicatrices
jistuleuses of Laennec. Occasionally one apex may be represented by a
series of these small cavities, surrounded by dense fibrous tissue. The
lining membrane of these old cavities may be quite smooth, almost like
a mucous membrane. Cavities of any size do not heal completely.
Cases are often seen in which it has been supposed that a cavity has
healed ; but the signs of excavation are notoriously uncertain, and there
may be pectoriloquy and cavernous sounds with gurgling, resonant rales
in an area of consolidation close to a large bronchus.
In the formation of vomicae the blood-vessels gradually become closed
by an obliterating inflammation. They are the last structures to yield
and may be completely exposed in a cavity, even when the circulation is
still going on in them. Unfortunately, the erosion of a large vessel which
has not yet been obliterated is by no means infrequent, and causes profuse
and often fatal haemorrhage. Another common event is the development
of aneurisms on the arteries running in the walls of cavities. These may
be small, bunch-like dilatations, or they may form cavities the size of a
walnut or even larger. Rasmussen, Douglas Powell and others have
called attention to their importance in haemoptysis, under which section
they are dealt with more fully.
And finally, about cavities of all sorts, the connective tissue develops
and tends to limit the extent. The thickening is particularly marked
beneath the pleura, and in chronic cases an entire apex may be converted
into a mass of fibrous tissue, enclosing a few small cavities.
(e) Pleura. — Practically, in all cases of chronic phthisis the pleura is
involved. Adhesions take place which may be thin and readily torn, or
dense and firm, uniting layers of from two to five millimetres in thickness.
This pleurisy may be simple, but in many cases it is tuberculous, and mili-
ary tubercles or caseous masses are seen in the thickened pleural mem-
218 SPECIFIC INFECTIOUS DISEASES.
brane. Pleural effusion is not at all infrequent, either serous, purulent,
or ha^morrhagic. Pneumothorax is a common accident.
(/) Changes in the smaller bronchi control the situation in the early
stages of tuberculous phthisis, and play an important role throughout the
disease. The process very often begins in the walls of the smaller tubes
and leads to caseation, distention with products of inflammation, and
broncho-pneumonia of the lobules. In many cases the visible implication
of the bronchus is an extension upward of a process which has begun in
the smallest bronchiole. This involvement weakens the wall, leading to
bronchiectasis, not an uncommon event in phthisis. The mucous mem-
brane of the larger bronchi, which is usually involved in a chronic catarrh,
is more or less swollen, and in some instances ulcerated.
(g) The hroiicliial glands^ in the more acute cases, are swollen and
cedematous. Miliary tubercles and caseous foci are usually present. In
cases of chronic phthisis the caseous areas are common, calcification may
occur, and not infrequently purulent softening.
(Ji) Changes in tlie other Organs. — Of these, tuberculosis is the most
common. In my series of autopsies the brain presented tuberculous
lesions in 31, the spleen in 33, the liver in 12, the kidneys in 32, the intes-
tines in 65, and the pericardium in 7. Other groups of lymphatic glands
besides the bronchial may be affected — the cervical, the mediastinal, and
the retro-peritoneal.
Certain degenerations are common. Amyloid change is frequent in
the liver, spleen, kidneys, and mucous membrane of the intestines. The
liver is often the seat of extensive fatty infiltration, which may cause
marked enlargement. The intestinal ttiherculosis occurs in advanced
cases and is responsible in great part for the troublesome diarrhoea.
Endocarditis is not very uncommon, and was present in 12 of my
post-mortems and in 27 of Percy Kidd's 500 cases. Tubercles may be
present on the endocardium, particularly of the right ventricle. As
pointed out by Norman Chevers and confirmed by subsequent writers, the
subjects of congenital stenosis of the pulmonary orifice very frequently
have phthisis.
The larynx is frequently involved, and ulceration of the vocal cords
and destruction of the epiglottis are not at all uncommon.
Modes of Onset. — We have already seen that tuberculosis of the
lungs may occur as the chief part of a general infection, or may set in
with symptoms which closely simulate acute pneumonia. In the ordiiuxry
type of pulmonary tuberculosis the invasion is gradual and less striking,
but presents an extraordinarily diverse picture, so that the practitioner is
often led into error. Among the most characteristic of these types of on-
set are the following : [a) With dyspeptic and ancemic symptoms, forming
a large and important group. The patients may naturally have had feeble
digestion. They begin to show marked signs of dyspepsia and become
pale, lose flesh, and look chlorotic before any pulmonary symptoms are
TUBERCULOSIS. 219
manifest, (b) With chills and fever. Tins mode of onset is particularly
important in malarial regions, as the diagnosis of ordinary intermittent
fever is often made, and the nature of the disease entirely overlooked.
In Phihidelphia it was very common to have patients sent to hospital
supposed to be suffering with mahiria, who had well-developed signs of
pulmonary tuberculosis, (c) Bronchitic onset. These are the instances
which arise in what the patient calls a neglected cold. The patient has
perhaps been subject to naso-pharyngeal catarrh, and has been liable to
take cold readily ; then a bronchial cough develops, -which proves intrac-
table. Sometimes the bronchitic symptoms are associated with wheezing,
like mild asthma. The development in these instances may be extremely
insidious and, without any special aggravation of the general symptoms
or increase in the fever, the tuberculous nature of the trouble may be
discovered accidentally by the examination of the sputum, [d) Onset
with hcemoptysis. The relation of haemoptysis to pulmonary tuberculosis
will be discussed elsewhere. The haemoptysis may come on in a con-
dition of robust health, and it occasionally, though rarely, happens that
the pulmonary symptoms follow rapidly. In other cases a long interval
elapses. Undoubtedly these are cases in which there has been a small
localized lesion in the lung which has not produced constitutional dis-
turbance, (e) Pleuritic onset. This may be a dry pleurisy, developing at
the apex or in a scapular region, or in some instances extending generally.
It may be acute pleurisy with effusion, or the effusion may have come on
insidiously without any acute manifestations. Phthisis developed in a
third of ninety cases of pleurisy with effusion, the subsequent history of
which was followed by Bowditch. (/) With laryngecd symptoms. In rare
instances huskiness and loss of voice are the symptoms for which the pa-
tient seeks advice, and the epiglottis or cords may be involved in a well-
characterized tuberculosis before the physical signs in the lungs are at all
clear. It is in these instances that the examination of the sputa is of the
greatest value.
These represent the usual modes of onset of the ordinary chronic
phthisis. It occasionally happens that in an instance with an acute pneu-
monic onset the severity of the symptoms subsides, and, instead of termi-
nating as a majority of these cases do within ten or twelve weeks, the case
drags on and becomes chronic.
Symptoms. — In discussing the symptoms it is usual to divide the
disease into three periods : the first embracing the time of the growth and
development of the tubercles; the second, in which they soften; and the
third, in which there is a formation of cavities. Unfortunately, these ana-
tomical stages can not be satisfactorily correlated with corresponding clini-
cal periods, and we often find that a patient in the third stage with well-
marked cavity is in a far better condition and has greater prospects of re-
covery than a patient in the first stage with diffuse consolidation. It is
therefore better perhaps to disregard them altogether.
220 SPECIFIC INFECTIOUS DISEASES.
1. Local Symptoms. — Pain in the chest may be early and troublesome
or absent throughout. It is usually associated with pleurisy, and may be
sharp and stabbing in character, and either constant or felt only during
coughing. Perhaps the commonest situation is in the lower thoracic
zone, though in some instances it is beneath the scapula or referred to the
apex. The attacks may recur at long intervals. Intercostal neuralgia
occasionally develops in the course of ordinary phthisis.
Cough is one of the earliest symptoms, and is present in the majority
of cases from beginning to end. There is nothing peculiar or distinctive
about it. At first dry and hacking, and perhaps scarcely exciting the
attention of the patient, it subsequently becomes looser, more constant,
and associated with a glairy, muco-purulent expectoration. In the early
stages of the disease the cough is bronchial in its origin. When cavities
have formed it becomes more paroxysmal, and is most marked in the
morning or after a sleep. Cough is not a constant symptom, however,
and a patient may present himself with well-marked excavation at one
apex who will declare that he has had little or no cough. So, too, there
may be well-marked physical signs, dulness and moist sounds, without
either expectoration or cough. In well-established cases the nocturnal
paroxysms are most distressing and prevent sleep. The cough may be of
such persistence and severity as to cause vomiting, and the patient becomes
rapidly emaciated from loss of food.
Sputum. — This varies greatly in amount and character at the different
stages of ordinary phthisis. There are cases with well-marked local signs
at one apex, with slight cough and moderately high fever, without from
day to day a trace of expectoration. So, also, there are instances with the
most extensive consolidation (caseous pneumonia), with high fever, and, as
in a recent instance under observation for several months, without enough
expectoration to enable an examination for bacilli to be made. In the
early stage of pulmonary tuberculosis the sputum is chiefly catarrhal and
has a glairy, sago-like appearance, due to the presence of alveolar cells
which have undergone the myelin degeneration. There is nothing dis-
tinctive or peculiar in this form of expectoration, which may persist for
months without indicating serious trouble. The earliest trace of charac-
teristic sputum is seen in the presence of small grayish or greenish-gray
purulent masses. These, when coughed up, are always suggestive and
should be the portions picked out for microscopical examination. As
softening comes on, the expectoration becomes more profuse and puru-
lent, but may still contain a considerable quantity of alveolar epithelium.
Finally, when cavities exist, the sputa assume the so-called nummular
form ; each mass is isolated, flattened, greenish-gray in color, quite airless,
and sinks to the bottom when spat into water.
By the microscopical examination of the sputum we determine whether
the process is tuberculous, and whether softening has occurred. For tu-
hercle bacilli the Ehrlich-Weigert method is the best. Eleven centimetres
TUBERCULOSIS. 221
of a saturated solution of fuchsin in absolute alcohol is added to one hun-
dred centimetres of the saturated solution of commercial aniline oil (made
by shaking up the oil in water and then filtering). This should be made
fresh every third or fourth day. A small bit of the sputum is picked out
on a needle or platinum wire and spread thin on the top-cover so as to
make a uniformly thin layer. The top-cover is slowly dried about a foot
above a Bunsen burner. Sufficient of the staining fluid is then dropped
upon the top-cover, which is held at a little distance above the flame un-
til the fluid boils. The staining fluid is then washed off in distilled water
or put under the tap, decolorized in thirty per cent nitric-acid fluid, again
washed off in water, and mounted on the slide. In doubtful cases the
long process is used, the cover-slips remaining twenty-four hours in the
stain. The bacilli are seen as elongated, slightly curved, red rods, some-
times presenting a beaded appearance. They are frequently in groups of
three or four, but the number varies considerably. Only one or two may
be found in a preparation, or, in some instances, they are so abundant
that the entire field is occupied.
The presence of these bacilli in the sputum is an infallihle indication
of the existence of tuberculosis.
Sometimes they are found only after repeated examination. They
may be abundant early in the disease and are usually numerous in the
nummular sputum of the later stages.
Elastic tissue may be derived from the bronchi, the alveoli, or from
the arterial coats ; and naturally the appearance of the tissue will vary
with the locality from which it comes. In the examination for this it is
not necessary to boil the sputum with caustic potash. For years I have
used a simple plan which was shown to me at the London Hospital by
Sir Andrew Clark. This method depends upon the fact that in almost
all instances if the sputum is spread in a sufficiently thin layer the frag-
ments of elastic tissue can be seen with the naked eye. The thick, puru-
lent portions are placed upon a glass plate fifteen by fifteen centimetres
and flattened into a thin layer by a second glass plate ten by ten centi-
metres. In this compressed grayish layer between the glass slips any
fragments of elastic tissue show on a black background as grayish-yellow
spots and can either be examined at once under a low power or the upper-
most piece of glass is slid along until the fragment is exposed, when it is
picked out and placed upon the ordinary microscopic slide. Fragments
of bread and collections of milk-globules may also present an opaque
white appearance, but with a little practice they can readily be recog-
nized. Fragments of epithelium from the tongue, infiltrated with micro-
cocci, are still more deceptive, but the microscope at once shows the dif-
ference.
The bronchial elastic tissue forms an elongated network, or two or
three long, narrow fibres are found close together. From the blood-ves-
sels a somewhat similar form may be seen and occasionally a distinct
222 SPECIFIC INFECTIOUS DISEASES.
sheeting is found as if it had come from the intima of a good-sized ar-
tery. The elastic tissue of the alveohir wall is quite distinctive ; the fibres
are branched and often show the outline of the arrangement of the air-
cells. The elastic tissue from bronchus or alveoli indicates extensive
erosion of a tube and softening of the lung-tissue.
Another occasional constituent of the sputum is blood, which may be
present as the chief constituent of the expectoration in haemoptysis or
may simply tinge the sputum. In chronic cases with large cavities, in
addition to bacteria, various forms of fungi may develop, of which the
aspergillus is the most important. Sarcinae may also occur.
The daily amount of expectoration varies. In rapidly advancing
cases, with much cough, it may reach as high as five hundred cubic centi-
metres in the day. In cases with large cavities the chief amount is
brought up in the morning. The expectoration of tuberculous patients
usually has a heavy, sweetish odor, and occasionally it is fetid, owing to
decomposition in the cavities.
Hcemoptysis. — Haemoptysis is met with either early in the disease, be-
fore there are physical signs, or during the course of the affection when
there is softening or excavation. A majority of the haemorrhages believed
to be precursory are really due to already existing disease of the lung, and
there is no ground whatever for the opinion, so long held, that phthisis
can originate directly from haemoptysis. The blood may be either pure
or mixed with sputum. A distinction should be made between these two
forms. When the sputa are simply tinged or the blood is admixed, it
comes, in all probability, from hyperaemic bronchial mucosa or locally
congested areas of lung-tissue ; but the brisk haemorrhage in which the
blood comes up in mouthfuls is always due to erosion of vessels, small or
large, in the process of softening, or, in the later stages of the disease,
comes from the erosion of a branch of the pulmonary artery or from a
ruptured aneurism of the pulmonary artery in a cavity. This latter is the
most frequent cause of the fatal haemorrhage in consumption.
Dyspnoea is not a common accompaniment of ordinary phthisis. The
greater part of one lung may be diseased and local trouble exist at the
other apex without any shortness of breath. Even in the paroxysms of
very high fever the respirations may not be much increased. Rapid ad-
vance, as of a broncho-pneumonic process, or the development of miliary
tubercles throughout the lung, causes great increase in the number of
respirations. A degree of dyspnoea leading to cyanosis is almost unknown,
apart from extensive invasion of the sound portions by miliary tubercles.
One reason why there is so little shortness of breath in phthisis is that
there is always a moderate grade of ani^mia, and the diminished lung-
space is sufficient to supply oxygen to the reduced number of blood-cor-
puscles.
2. General Symptoms. — Fever. — To get a correct idea of the tempera-
ture range in pulmonary tuberculosis it is necessary, as Kinger pointed
TUBERCULOSIS. 223
out, to make tolerably frequent observations. The usual 8 A. m. and 8 p. m.
record is, in a majority of the cases, very deceptive, giving neither the
minimum nor maximum. Tlie former usually occurs between 2 and G A. M.
and the latter between 2 and G p. m.
A recognition of various forms of fever, viz., of tuberculization, of
ulceration, and of absorption, emj:)hasizes the anatomical stages of growth,
softening and cavity formation ; but practically such a division is of little
use, as in a majority of cases these processes are going on together.
Fever is the most important initial symptom and throughout the entire
course the thermometer is the most trustworthy guide as to the progress
of the affection. With pyrexia a patient loses in weight and strength,
and the local disease usually progresses. The periods of apyrexia are
those of gain in weight and strength and in limitation of the local lesion.
It by no means necessarily follows that a patient with tuberculosis has
pyrexia. There may be quite extensive disease without coexisting fever.
At the moment of writing, I have eighteen instances of chronic phthisis
under observation, of whom ten are practically free from fever ; but in the
early stage, when tubercles are developing and caseous areas are in pro-
cess of formation and when softening is in progress, fever is a constant
symptom. It was present in one hundred consecutive cases at my dis-
pensary service.
Two types of fever are seen — the remittent and the intermittent.
These may occur indifferently in the early or in the late stages of the
disease or may alternate with each other, a variability which depends upon
the fact that phthisis is a progressive disease and that all stages of lesions
may be found in a single lung. Special stress should be laid upon the
fact, particularly in malarial regions, that tuberculosis may set in with a
fever typically intermittent in character — a daily chill, with subsequent
fever and sweat. In Montreal, where malaria is practically unknown,
this was alw^ays regarded as a suggestive symptom ; but in Philadelphia
and Baltimore, where ague prevails, it is no exaggeration to say that yearly
scores of cases of early tuberculosis are treated for ague. These are often
cases that pursue a rapid course. The fever of onset — tuberculization —
may be almost continuous, with slight daily exacerbations ; and at any
time during the course of chronic phthisis, if tliere is rapid extension,
the remissions become less marked.
A remittent fever, in which the temperature is constantly above
normal but drops two or three degrees toward morning, is not uncommon
in the middle and later stages and is usually associated with softening
or extension of the disease. Here, too, a simple morning and evening
register may give an entirely erroneous idea as to the range of the fever.
With breaking down of the lung-tissue and formation of cavities, associ-
ated as these i)rocesscs always are with suppuration and with more or less
systemic contamination, the fever assumes a chjiracteristically intermittent
or hectic type. For a large part of the day the patient is not only afebrile,
224:
SPECIFIC INFECTIOUS DISEASES.
bat the temperature is subnormal. In the annexed two-hourly chart,
from a case of chronic tuberculosis of the lungs, it will be seen that from
10 P. M. to 8 or 12 A. M., the temperature continuously fell and reached
as low as 95°. A slow rise then took place through the late morning and
early afternoon hours and reached its maximum between 6 and 10 p. m.
As shown in the chart there were in the three days about forty- three
hours of pyrexia and twenty-nine hours of apyrexia. The rapid fall of
Jan. 12
Temp
109
Resp.
■~^/^
^\<~
i '■ a 3- a ■■ a J 3_: a : a ' a ; § ' : a '■ a ■ a- ^ • ^
'^ ; iu' o.'; 0,': & :"*■ •'< : <: '< ■ ^ ^s. »< aT a." ;"~ . *".
a a ; a a ^ ? : a ^ a a' ; a *. : • ■ a a ' a ; a
Chart XIII. — Three days. Chronic tuberculosis.
the temperature in the early morning hours is usually associated with
sweating. This hectic, as it is called, which is a typical fever of septic
infection, is met with when the process of cavity formation and softening
is advanced and extending.
A continuous fever with remissions of not more than a degree, develop-
ing in the course of pulmonary tuberculosis, is suggestive of acute pneu-
monia. When a two-hourly chart is made, the remissions even in acute
tuberculous pneumonia ai'C usually well marked. A continued fever, such
TUBERCULOSIS. 225
as is seen in the first week of typhoid, or in some cases of inflammation
of the lung, is rare in tuberculosis.
Sweating. — Drenching perspirations are common in phthisis and con-
stitute one of the most distressing features of the disease. They occur
usually at night, or at any time in the day when the patient sleeps. They
may come on early in the disease, but are more persistent and frequent
after cavities have formed. Some patients escape altogether.
^\iQ pulse is increased in frequency, especially when the fever is high.
It is often remarkably full, though soft and compressible. Pulsation may
sometimes be seen in the capillaries and in the veins on the back of the
hand.
Emaciation is a pronounced feature. The loss of weight is gradual
but, if the disease is extending, progressive. The scales give one of the
best indications of the progress of the case.
3. Physical Signs. — («) Inspection. — The shape of the chest is often
suggestive, though it is to be remembered that pulmonary tuberculosis
may be met with in chests of any build. Practically, however, in a con-
siderable proportion of cases the thorax is long and narrow, with very
wide intercostal spaces, the ribs more vertical in direction and the costal
angle very narrow. The scapulae are " winged," a point noted by Hip-
pocrates. Another type of chest which is very common is that which is
flattened in the antero-posterior diameter. The costal cartilages may be
prominent and the sternum depressed. Occasionally the lower sternum
forms a deep concavity, the so-called funnel breast {Trichter-Brust). In-
spection gives valuable information in all stages of the disease. Special
examination should be made of the clavicular regions to see if one clavicle
stands out more distinctly than the other, or if the spaces above or below
it are more marked. Defective expansion at one apex is an early and im-
portant sign. The condition of expansion of the lower zone of the thorax
may be well estimated by inspection. The condition of the praecordia
should also be noted, as a wdde area of impulse, particularly in the second,
third, and fourth interspaces, often results from disease of the left apex.
From a point behind the patient, looking over the shoulders, one can
often better estimate the relative expansion of the apices.
{b) Palpation. — Deficiency in expansion at the apices or bases is per-
haps best gauged by placing the hands in the subclavicular spaces and
then in the lateral regions of the chest and asking the patient to draw
slowly a full breath. Standing behind the patient and placing the
thumbs in the supraclavicular and the fingers in the infraclavicular
spaces one can judge accurately as to the relative mobility of the two
sides. Disease at an apex, though early and before dulness is at all
marked, may be indicated by deficient expansion. On asking the patient
to count, the tactile fremitus is increased wherever there is local growth of
tubercle or extensive caseation. In comparing the apices it is important
to bear in mind that normally the fremitus is stronger at the right than
226 SPECIFIC INFECTIOUS DISEASES.
at the left. So too at the base, when there is consolidation of the lung,
the fremitus is increased ; whereas, if there is pleural effusion, it is
diminished or absent. In the later stages, when cavities form, the tactile
fremitus is usually much exaggerated over them. When the pleura is
greatly thickened the fremitus may be somewhat diminished.
(c) Percussi07i. — Tubercles, inflammatory products, fibroid changes,
and cavities produce important changes in the pulmonary resonance.
There may be localized disease, even of some extent, without inducing
much alteration ; as when the tubercles are scattered and have air-con-
taining tissue between them. One of the earliest and most valuable signs
is defective resonance upon and above a clavicle. In a considerable pro-
portion of all cases of phthisis the dulness is first noted in these regions.
The comparison between the two sides should be made also when the
breath is held after a full inspiration, as the defective resonance may then
be more clearly marked. In the early stages the percussion note is usually
higher in pitch and may require an experienced ear to detect the differ-
ence. In recent consolidation from caseous pneumonia the percussion
note often has a tubular or tympanitic quality. A wooden dulness is
rarely heard except in old cases with extensive fibroid change at the apex
or base. Over large, thin- walled cavities at the apex the so-called cracked-
pot sound may be obtained. In thin subjects the percussion should be
carefully practised in the supraspinous fossae and the interscapular space,
as they correspond to very important areas early involved in the disease.
In cases with numerous separated cavities at the apex, without much
fibroid tissue or thickening of the pleura, the percussion note may show
little change, and the contrast between the signs obtained on auscultation
and percussion is most marked.
{d) AuscuUatioii. — Feeble breath-sounds are among the most charac-
teristic early signs, since not as much air enters the tubes and vesicles of
the affected area. It is well at first always to compare carefully the cor-
responding points on the two sides of the chest without asking the patient
either to draw a deep breath or to cough. With early apical disease the
inspiration on quiet breathing may be scarcely audible. Expiration is
usually prolonged. On the other hand there are cases in which tlie earliest
sign is a harsh, rude, respiratory murmur. On deep breathing it is fre-
quently to be noted that inspiration is jerking or wavy, the so-called " cog-
wheel " rhythm ; which, however, is by no means confined to tuberculosis.
With extension of the disease the inspiratory murmur is harsh, and, when
consolidation occurs, whiffing and bronchial. AVith these changes in the
character of the murmur tliere are rales, due to the accompanying bron-
chitis. They may be heard only on deep inspiration or on coughing, and
early in the disease are often crackling in character. When softening
occurs they are louder and have a bubbling, sometimes a characteristic
clicking quality. These " moist sounds," as they are called, when asso-
ciated with change in the percussion resonance are extremely suggestive.
TUBERCULOSIS. 227
When cavities form, the rdles are louder, more gurgling, and resonant in
quality. AVhen there is consolidation of any extent the breath-sounds are
tubular, and in the large excavations loud and cavernous, or have an am-
phoric quality. In the unaffected portions of the lobe and in the opposite
lung the breath-sounds may be harsh and even puerile. The vocal reso-
nance is usually increased in all stages of the process, and bronchophony
and pectoriloquy are met with in the regions of consolidation and over
cavities. Pleuritic friction may be present at any stage and, as mentioned
before, occurs very early. There are cases in which it is a marked feature
throughout. When the lappet of lung over the heart is involved there
may be a pleuro-pericardial friction, and when this area is consolidated
there may be curious clicking rales synchronous with the heart-beat, due
to the compression by the heart of, and the expulsion of air from, this
portion. An interesting auscultatory sign, met most commonly in phthisis,
is the so-called cardio-respiratory murmur, a whiffing systolic bruit due to
the propulsion of air out of the tubes by the impulse of the heart. It is
best heard during inspiration and in the antero-lateral regions of the chest.
A systolic murmur is frequently heard in the subclavian artery on
either side, the pulsation of which may be very visible. The murmur is
in all probability due to pressure on the vessels by the thickened pleura.
The signs of cavity may be here briefly enumerated.
(a) When there is not much thickening of the pleura or condensation
of the surrounding lung-tissue, the percussion sound may be full and
clear, resembling the normal note. More commonly there is defective
resonance or a tympanitic quality which may at times be purely amphoric.
The pitch of the percussion note changes over a cavity when the mouth
is opened or closed (Wintrich's sign), or it may be brought out more
clearly on change of position. The cracked-pot sound is only obtainable
over tolerably large cavities with thin walls. It is best elicited by a firm,
quick stroke, the patient at the time having the mouth open. In those
rare instances of almost total excavation of one lung the percussion note
may be amphoric in quality, (b) On auscultation the so-called cavernous
sounds are heard : (1) Various grades of modified breathing — blowing or
tubular, cavernous or amphoric. There may be a curiously sharp hissing
sound, as if the air was passing from a narrow opening into a wide space.
In very large cavities both inspiration and expiration may be typically
amphoric. (2) There are coarse bubbling rales which have a resonant
quality, and on coughing may have a metallic or ringing character. On
coughing they are often loud and gurgling. In very large thin-wallcd
cavities, and more rarely in medium-sized cavities, surrounded by recent
consolidation, the rales may have a distinctly amphoric echo, simulating
those of pneumothorax. There are dry cavities in which no rales are
heard. (3) The vocal resonance is greatly intensified and whispered
pectoriloquy is clearly heard. In large apical cavities the heart-sounds
are well heard, and occasionally there may be an intense systolic murmur.
228 SPECIFIC INFECTIOUS DISEASES.
probably always transmitted to, and not produced, as has been supposed,
in the cavity itself.
Pseudo-cavernous signs may be caused by an area of consolidation
near a large bronchus. The condition may be most deceptive — the high-
pitched or tympanic percussion note, the tubular or cavernous breathing,
and the resonant rales, simulate closely those of cavity.
4. Symptoms referable to other Organs. — (a) Car dio-vasc alar. — The
retraction of the left upper lobe exposes a large area of the heart. In
thin-chested subjects there may be pulsation in the second, third, and
fourth interspaces close to the sternum. Sometimes with much retraction
of the left upper lobe the heart is drawn up. A systolic murmur over the
pulmonary area is common in all stages of phthisis. Apical murmurs are
also not infrequent and may be extremely rough and harsh without neces-
sarily indicating that endocarditis is present. The association of heart-
disease with phthisis is not, however, very uncommon. As already men-
tioned, there were twelve instances of endocarditis in 216 autopsies. The
arterial tension is usually low in phthisis and the capillary resistance les-
sened so that the pulse is often full and soft even in the later stages of
the disease. The capillary pulse is not infrequently met with, and pulsa-
tion of the veins in the back of the hand is occasionally to be seen.
(b) Blood Glandular System. — The early ansemia has already been
noted. It is often more apparent than real, a chloro-ansemia, and the
blood-count rarely sinks below two million per cubic millimetre.
The blood-plates are, as a rule, enormously increased and are seen in
the withdrawn blood as the so-called Schultze's granule masses.
(c) G astro-intestinal System. — The tongue is usually furred, but may
be clean and red. Small aphthous ulcers are sometimes distressing. A
red line on the gums, a symptom to Avhich at one time much attention was
paid as a special feature of phthisis, occurs in other cachectic states. Ex-
tensive tuberculous disease of the pharynx, associated with similar affec-
tion of the larynx, may interfere seriously with deglutition and prove a
very distressing and intractable symptom.
Of late, special attention has been paid to the gastric symptoms of this
affection. Tuberculous disease is rare. I have seen but one undoubted
specimen from a case which Musser has reported.* Ulceration may occur
as an accidental complication and multiple catarrhal ulcers are not uncom-
mon. Interstitial and parenchymatous changes in the mucosa are com-
mon (possibly associated with the venous stasis) and lead to atrophy, but
these cannot always be connoted with the symptoms, and they may be
found when not expected. On the other hand, when the gastric symp-
toms have been most persistent, the mucosa may show very little change.
It is impossible always to refer the anorexia, nausea, and vomiting of con-
sumption to local conditions. The hectic fever and the neurotic influ-
* Philadelphia Hospital Reports, vol. i, 1890.
TUBERCULOSIS. 229
ences, upon wliich Immermann la\'s much stress, must be taken into ac-
count, as they phiy an important ro/e. The organ is often dilated, and to
muscular insufficiency alone may be due some of the cases of dyspepsia.
The condition of the gastric secretion is not constant, and the reports are
discordant. In the early stages there may be hyperacidity ; later, a de-
ficiency of acid.
Anorexia is often a marked symptom at the onset ; there may be positive
loathing of food, and even small quantities cause nausea. Sometimes with-
out any nausea or distress after eating the feeding of the patient is a daily
battle. When practicable, Debove's forced alimentation is of great benefit
in such cases. Nausea and vomiting, though occasionally troublesome at
an early period, are more marked in the later stages. The latter may be
caused by the severe attacks of coughing. S. H. Habershon refers to four
different causes the vomiting in phthisis : (1) central, as from tuberculous
meningitis ; (2) pressure on the vagi by caseous glands ; (3) stimulation
from the peripheral branches of the vagus, either pulmonary, pharyngeal,
or gastric ; and (4) mechanical causes.
Of the intestinal symptoms diarrhoea is the most serious. It may
come on early, but is more usually a symptom of the later stages, and
is associated with ulceration, particularly of the large bowel. Extensive
ulceration of the ileum may exist without any diarrhoea. The associated
catarrhal condition may account in part for it, and in some instances the
amyloid degeneration of the mucous membrane.
{d) Nervous System. — (1) Focal lesions due to the development of
coarse tubercles and areas of tuberculous meningo-encephalitis. Aphasia,
for instance, may result from the growth of meningeal tubercles in the
fissure of Sylvius, or even hemiplegia may develop. The solitary tuber-
cles are more common in the chronic phthisis of children. (2) Basilar
meningitis is an occasional complication. It may be confined to the
brain, though more commonly it is a (3) cerebro-spinal meningitis, which
may come on in persons without well-developed local signs in the chest.
Twice have I known strong, robust men brought into hospital with signs
of cerebro-spinal meningitis, in whom the existence of pulmonary disease
was not discovered until the post-mortem. (4) Peripheral neuritis. This
is not frequent, and has occurred but five times in the large number of
consumptives who have come under my observation during the past seven
years. It is nearly always an extensor paralysis of the arm or leg, more
commonly the latter, causing foot-drop. It is usually a late manifes-
tation. (5) Mental symptoms. It was noted, even by the older writers,
that consumptives had a peculiarly hopeful temperament, and the spes
pJithisica forms a curious characteristic of the disease. Patients with ex-
tensive cavities, high fever, and too weak to move will often make plans
for the future and confidently expect to recover.
Apart from tuberculosis of the brain, there is sometimes in chronic
phthisis a form of insanity not unlike that which develops in the conva-
230 SPECIFIC INFECTIOUS DISEASES.
lescence from acute affections. The whole question of the mutual relations
of insanity and j^^ithisis is dealt with at length in Mickle's Gulstonian
lectures.
(e) A remarkable hypertrophy of the mammary gland may occur in
pulmonary tuberculosis,* most commonly in males. It may only be on the
affected side. Two cases came under my notice at the University Hospital,
Philadelphia, both in young males. It is a chronic interstitial, non-tuber-
culous mammitis (Allot).
(/) Genito-urinary System. — The urine presents no special peculiari-
ties in amount or constituents. Fever, however, has a marked influence
upon it. Albumen is met with frequently and may be associated with
the fever, or is the result of definite changes in the kidneys. In the latter
case it is more abundant and more curd-like. Amyloid disease of the
kidneys is not uncommon. Its presence is shown by albumen and tube-
casts in the urine, and sometimes by a great increase in the amount of
urine. In other instances there is dropsy, and the patients have all the
characteristic features of chronic Bright's disease.
Pus in the urine may be due to disease of the bladder or of the
pelves of the kidneys. In some instances the entire urinary tract is in-
volved. In pulmonary phthisis, however, extensive tuberculous disease is
rarely found in the urinary organs. Bacilli may occasionally be detected
in the pus. Haematuria is not a very common symptom. It may occur
occasionally as a result of congestion of the kidneys, which passes off and
leaves the urine albuminous. In other instances it results from disease of
the pelvis or of the bladder, and is associated either with early tubercu-
losis of the mucous membranes or more commonly with ulceration.
(g) Cutaneous System. — The skin is often dry and harsh. Local
tubercles occasionally develop on the hands. There may be pigmentary
staining, the cliloasma phthisicorum^ which is more common when the
peritonaeum is involved. Upon the chest and back the brown stains of
the pityriasis versicolor are very frequent. The hair of the head and
beard may become dry and lanky. The terminal phalanges, in chronic
cases, become clubbed and the nails incurvated — the Ilippocratic fingers.f
A remarkable and unusual complication is general emphysema, which may
result from ulceration of an adherent lung or perforation of the larynx.
Diagnosis. — When well advanced there is rarely any doubt as to the
existence of tuberculous phthisis, for the sputum gives positive informa-
tion, and the ])hysical signs of local disease are well marked. The bacilli
give an infallible indication of the existence of tuberculosis and may be
found in the sputum before the physical signs are at all definite. On the
other hand, it must be remembered that there are cases in which, even
* Allot, Paris Thesis, 1887.
f '• Morbo progrediente, corpus macrescit prjEter crura: ha?c autcra tument et
pedes, et ungues contorquentur " (Ilippocrates).
TUBERCULOSIS. 231
with tolerably well-defined physical signs, the sputum is extremely scanty
and many examinations may be required to detect tubercle bacilli. So
essential is the examination of the sputum in the early diagnosis of phthi-
sis that I would earnestly insist upon the more frequent employment of
this method. There is no excuse now for its omission, since, if the prac-
titioner has not command of the necessary technique, there are labora-
tories in many parts of the country at which the examination can be made.
Early detection is of vital importance^ as successful treatment depends
upon the measures taken before the lung is extensively involved.
The presence of elastic fibres in the sputum is an indication of destruc-
tion of the lung- tissue. In a large proportion of cases it is indicative, too,
of tuberculous disease. It also may be found early, before the physical
signs are well marked. Its detection is easy by the above-mentioned
method, not requiring high powers of the microscope. In cases of early
hsemoptysis, before there is marked constitutional disturbance, or even
local signs, it is very important to make a thorough examination of the
sputum, from which mucoid and purulent portions may be picked out for
examination. AVitli localized and persistent signs in one lung, cough,
fever, and loss of flesh, the diagnosis is rarely dubious. It is remarkable,
however, to what an extent the local process may sometimes proceed with-
out disturbance of health sufficient to excite the alarm of the physician or
friends. There are puzzling cases with localized physical signs at one apex,
chiefly moist rales, rarely any percussion changes, perhaps slight fever, and
a glairy expectoration containing numerous alveolar cells. I have seen
several cases of this kind which have been for a time very obscure, and in
which repeated examinations failed to detect either bacilli or elastic tissue.
They seem to be instances of local catarrhal trouble in the smaller tubes,
some of which clear in a few weeks.
3. Fibroid Phthisis.
In the section on diseases of the lungs we shall refer to the chronic in-
terstitial pneumonia, or cirrhosis of the lung, which may be a sequence of
acute lobar pneumonia, or follow a chronic pleurisy, or is due to inhala-
tion of dust, as in anthracosis. From these causes a condition of sclerosis
or induration of the lung may be produced with gradual shrinkage. An
identical condition is present in certain cases of chronic pulmonary
tuberculosis, and to this it is best perhaps to limit the i^vvti fibroid phthi-
sis. This form may come on gradually as a sequence of a chronic tuber-
culous broncho-pneumonia, or follow a chronic tuberculous pleurisy. In
other instances the process supervenes upon an ordinary ulcerative phthi-
sis. The disease becomes limited to one apex, the cavity is surrounded by
layers of dense fibrous tissue, the pleura is thickened, and the lower lobe
is gradually invaded by the sclerotic change. Ultimately a picture is
produced little if at all different from the other forms of cirrhosis of the
16
232 SPECIFIC INFECTIOUS DISEASES.
lungs. It may even be difficult to say that the process is tuberculous, but
in advanced cases the bacilli are usually present in the walls of the cavity
at the apex, or old, encapsulated caseous areas exist in the lung, or there
may be tubercles at the apex of the other lung and in the bronchial
glands. Dilatation of the bronchi is present ; the right ventricle, some-
times the entire heart, is hypertrophied.
The disease is chronic, lasting from ten to twenty or more years, dur-
ing which time the patient may have fair health.
The chief symptoms are cough, which is often paroxysmal in character
and most marked in the morning. The expectoration is purulent, and
in some instances, when the bronchiectasis is extensive, foetid. There is
dyspnoea on exertion, but little or no fever.
The physical signs are very characteristic. The chest is sunken and
the shoulder lower on the affected side ; the heart is often drawn over and
displaced. If the left lung is involved there may be an unusually large
area of cardiac pulsation in the third, fourth, and fifth interspaces. Heart-
murmurs are common. There is dulness over the affected side and defi-
cient tactile fremitus. At the apex there may be well-marked cavernous
sounds ; at the base, distant bronchial breathing. The condition may
persist indefinitely. In some cases the other lung becomes involved, or
the patient has repeated attacks of haemoptysis, in one of which he dies.
As a result of the chronic suppuration, amyloid degeneration of the liver,
spleen, and intestines may take place ; dropsy frequently supervenes from
failure of the right heart.
A more detailed account is found under Cirrhosis of the Lung, with
which this form is clinically identical.
Diseases associated with Pulmonary Tuberculosis.
Lobar pneumonia is not an uncommon cause of death. It is met with
most frequently, indeed, as a terminal event in the chronic cases. It
may, however, occur early, and be difficult to distinguish from an acute
caseous pneumonia. The sputa in the latter are rarely rusty, while the
fever in the former is more continuous and higher, but in many cases it
is impossible to differentiate between the two conditions.
Typhoid fever is rare in phthisis, but cases unquestionably occur. In
Case 8 of my series of post-mortems in this disease, a girl, aged eighteen,
had peritoneal adhesions, local disease at both apices, and perfectly char-
acteristic enteric lesions. In Case SJf.^ a male, aged twenty-five, with tuber-
culous cavities, had a very acute attack. The Peyer's glands were greatly
swollen with adlierent sloughs. The spleen weighed 533 grammes. The
characters of the ulceration are usually distinctive.
Erysipelas not infrequently attacks old poitrinaires in hospital wards
and almshouses. There are instances in which the attack seems to be
beneficial, as the cough lessens and the symptoms ameliorate. It may,
however, prove fatal, as in a recent case admitted to my wards.
TUBERCULOSIS. 233
The ertiptive fevers, 'particulixrly measles, frequently precede, but rarely
develop in the course of pulmonary tuberculosis. In the revaccination
of a tuberculous subject the vesicles run a normal course.
Fistula in ano is associated with phthisis in an interesting manner.
In a majority of such cases it is a tuberculous process. The general affec-
tion may progress rapidly after an operation. The question is considered
in tuberculosis of the alimentary canal.
In chronic and arrested phthisis arteriosclerosis is not uncommon.
Ormerod noted thirty cases of chronic renal disease in one hundred post
mortems.
The association of tuberculosis with chronic arthritis, upon which
certain writers lay stress, finds its explanation in the lowered resistance of
these patients, and the greater liability to infection in the institutions in
which so many of them live.
Peculiarities of Pulmonary Tuberciclosis at the Extremes of Life.
(a) Old Age. — It is remarkable how common tuberculosis is in the
aged, particularly in institutions. McLachlan noted a hundred and forty-
five cases in which tuberculosis was the cause of death in old persons in
Chelsea Hospital. All were over sixty years of age. The experience at
Salpetriere is the same. Laennec met with a case in a person over ninety-
nine years of age.
At the Philadelphia Hospital, in the bodies of aged persons sent over
from the almshouse it was extremely common to find either old or recent
tuberculosis. A patient died under my care at the age of eighty-two with
extensive peritoneal tuberculosis. Pulmonary tuberculosis in the aged is
usually latent and runs a slow course. The physical signs are often masked
by emphysema and by the coexisting chronic bronchitis. The diagnosis
may depend entirely upon the discovery of the bacilli and elastic tissue.
Contrary to the opinion which was held some years ago, tuberculosis is by
no means uncommon with senile emphysema. Some of the cases of tuber-
culosis in the aged are instances of quiescent disease which may have
dated from an early period.
(b) Infants. — The occurrence of acute tuberculosis in children has al-
ready been mentioned, and also the fact that the disease is occasionally
congenital. Recent studies, particularly of French writers, have shown
that it is a frequent affection in children under two years of age. Leroux
has analyzed the statistics of the late Prof. Parrot, embracing 219 cases in
children under three years. Of these there were from one day to three
months, 23 ; from three to six months, 35 ; from six to twelve months,
53 (a total of 111 under one year) ; and from one to two years, 108. Pul-
monary cavities were present in 57 of the cases, and in only 50 was the
pulmonary lesion the sole manifestation. At the St. Petersburg Found-
ling Asylum, in the ten years ending 1884, there were 410 cases of tuber-
culosis in 10,581 autopsies. The observations of North rup, at the New
2S4: SPECIFIC INFECTIOUS DISEASES.
York Foundling Hospital, are of special interest in connectien with the
mode of infection. Of 125 cases of tuberculosis on the records of this in-
stitution, in 34 the ravages were extensive, the seat of the primary affec-
tion was not clear, and the bronchial glands were large and cheesy. In
20 cases of general tuberculosis there were cheesy masses in the bronchial
glands and in the lungs. In 42 cases of general tuberculosis the only
cheesy masses were in the bronchial lymph-glands. In 9 cases the tuber-
cles were limited to the bronchial nodes and the lungs ; the latter contain-
ing only discrete miliary bodies, while the bronchial glands were in ad-
vanced caseation. In 13 cases there was tuberculosis of the bronchial
nodes only. In most of these cases the patients died of infectious dis-
eases. These figures are very suggestive, and point, as already noted, to
infection through the bronchial passages as the most common method,
even in children. Of 500 autopsies in children at the Munich Pathologi-
cal Institute, in 150 (thirty per cent) tuberculosis was present and in over
ninety-two per cent the lungs were involved (Miiller).
Modes of Death in Pulmonary Tuberculosis.
(a) By asthenia, a gradual failure of the strength. The end is usu-
ally peaceable and quiet,* occasionally disturbed by paroxysms of cough.
Consciousness is often retained until near the close.
(b) By asphyxia, as in some cases of acute miliary tuberculosis and
in acute pneumonic phthisis. In chronic phthisis it is rarely seen, even
when pneumothorax develops.
(c) By syncope. This is not common. I have known it to happen
once or twice in patients who insisted upon going about when in the ad-
vanced stages of the disease. There may be, but not necessarily, fatty de-
generation of the heart. A rapidly developing syncope may follow haemor-
rhage or may be due to thrombosis or embolism of the pulmonary artery,
or to pneumothorax.
(d) From hcemorrhage. The fatal bleeding in chronic phthisis is due
to erosion of a large vessel or rupture of an aneurism in the pulmonary
cavity, most commonly the latter. Of twenty-six analyzed by S. West, in
eleven cases the fatal haemoptysis was due to aneurism, and of thirty-five
cases collected by Percy Kidd, aneurism was present in thirty. In a case
of Curtin's, at the Philadelphia Hospital, the bleeding proved fatal before
haemoptysis occurred, as the eroded vessel opened into a capacious
cavity.
(e) With cerebral symptoms. Coma may be due to meningitis, less
often to uraemia. Deatli in convulsions is rare. The haemorrhagic pachy-
meningitis which develops in some cases of phthisis occasionally causes
loss of consciousness, but is rarely a direct cause of death. In one of my
* As is so well described by Sir Thomas Browne, whose Letter to a Friend gives
a unique account of the lp,st illness of a consumptive. Hood's Death-bed is true of
phthisis more frequently than of any other disease.
TUBERCULOSIS. 235
cases, death resulted from thrombosis of the cerebral sinuses with symp-
toms of meningitis.
V. Tuberculosis of the Serous Membranes.
General Pleuro-peritoneal Tuberculosis. — There are interesting cases
in which the lesions are confined almost entirely to the serous sacs —
the pleura, pericardium, and peritonaeum. I do not here refer to instances
of chronic pulmonary tuberculosis, in which the pleura and the perito-
naeum may be involved, but to the primitive form, in which these serous
membranes are involved in either (a) mi acute miliary i?iflam?nation ; (l>)
a chronic ulcerative tuberculosis ; or (c) a chronic fibroid tubef'culosis.
It is sufficient to indicate here the fact that cases occur involving pri-
marily the pleura and peritonaeum alone, sometimes with the pericardium,
and to pass on to the consideration of the affections of the individual sacs.
Tuberculosis of the Pleura. — This may be primary or secondary.
Primary tuberculosis of the pleura occurs as an acute process asso-
ciated with a sero-fibrinous or haemorrhagic exudate. Unquestionably
many of the cases regarded as pleurisy from cold are of this nature. It
may be truly primary, but in many instances local tuberculous disease
exists in lung or lymph-glands. There is a primary chronic tuberculosis
of the pleura. This produces great thickening and caseation of both
layers, which are sejoarated from each other by a thin infiltrated connect-
ive tissue, in which miliary granulations may sometimes be seen. The
pleural layers together may have a thickness of from five to ten millime-
tres. It is a comparatively rare affection. I found one of the most
striking illustrations of the kind in a young, remarkably healthy-looking
Irish girl, who died under my care of malignant scarlet fever. There
were no other tuberculous lesions in the body. The condition may be
unilateral or bilateral.
Seco7idary tuberculous pleurisy is very common. The visceral layer is
always involved in pulmonary tuberculosis. Adhesions usually form and
a chronic pleurisy results, which may be simple, but usually tubercles are
scattered through the adhesions. An acute tuberculous pleurisy may re-
sult from direct extension. The fluid may be sero-fibrinous or haemor-
rhagic, or may become purulent. And, lastly, a very common event in
pulmonary tuberculosis is the perforation of a superficial spot of softening,
and the production of pyo-pneumothorax.
The general symptomatology of these forms will be considered under
diseases of the pleura.
Tuberculosis of the Pericardium. — Miliary tubercles may occur as
a part of a general infection, but the term is properly limited to those
cases in which, either as a primary or secondary process, there is extensive
disease of the membrane. Tuberculosis is not so common in the peri-
cardium as in the pleura and peritonaeum, but it is certainly more com-
236 SPECIFIC INFECTIOUS DISEASES.
mon tlian the literature would lead us to suppose. Only thirty references
are noted in the Index Catalogue of the Surgeon-General's Office. It
occurs in two forms — chronic and acute.
(a) Clirouic Tuberculous Pericarditis. — This may occur as a primary
affection associated only with the caseation of the bronchial or particu-
larly the anterior mediastinal lymph-glands. More commonly there is
tuberculous disease elsewhere, either of the pleura or of the lungs, some-
times of the peritonaBum. In a number of cases the pericarditis is only a
part of a general infection of the serous membranes. The instances are
yery rare in which the process is confined to the pericardium. In one of
my cases, a man aged seventy-two, who died of pneumonia in the Phila-
delphia Hospital, the pericardium was thickened, both leaves were adher-
ent and presented cheesy masses and gray nodules. The heart weighed
55-1 grammes ; the bronchial glands were calcified ; there were no tuber-
cles in the other organs. The disease occurs at all ages. My young-
est case was in a child, aged five, in whom both layers of the pericardium
were greatly thickened and cheesy. In nearly every instance the bron-
chial or mediastinal glands are tuberculous. Occasionally it is due to
extension from tuberculous disease of the sternum or of the spine ; occa-
sionally to extension from the lungs. In one case, a man, aged fifty, who
died in the Philadelphia Hospital, the outer layer of the pericardium was
alone involved and thickened, in connection with a tuberculous abscess in
the anterior mediastinum. The condition is usually unsuspected. The
physical signs are those of hypertrophy of the heart. In a recent case the
organ weighed 60€ grammes, and the clinical symptoms were those of
hypertrophy and dilatation.
The physical signs are somewhat uncertain, since they are those of ad-
herent pericardium. The dulness may reach high along the left sternal
margin, and in one case, in which it was as high as the middle of the
manubrium, the thickened pericardial layers formed a solid cheesy mass
which surrounded the aorta.
(b) Acute Tuberculous Pericarditis. — This may occur as a secondary
infection from tubercle in other parts, or it may arise by direct extension
from the lungs, or more commonly by invasion from mediastinal lymph-
glands. The exudation may be limited in amount and chiefly fibrinous,
or it may be serous, and in many cases is haemorrhagic. Unless carefully
sought for, the tubercles may be overlooked. Lastly, some of the cases of
purulent pericarditis are tuberculous. The membranes may be much
thickened and no trace of tubercles apparent. The nature of the case
may, then, be gathered chiefly from the existence of tuberculous bronchial
or mediastinal glands, or the existence of tuberculous foci in other re-
gions. The effusion in these cases may be enormous, as in one reported
by Musser, in which the sac contained sixty- four ounces of fluid.
The symptoms and physical signs of this condition will be considered
with those of ordinary pericarditis with effusion.
TUBERCULOSIS. 237
{(I) Tuberculosis of the Peritonaeum. — In connection with miliary and
chronic puimonjiry tuberculosis it is not uncommon to find the peritonaium
studded with small gray granulations. They are constantly present on
the serous surface of tuberculous ulcers of the intestines. Apart from
these conditions the membrane is often the seat of extensive tuberculous
disease, which occurs in the following forms :
(1) Acute miliary tuberculosis with sero-fibrinous or bloody exuda-
tion.
(2) Clironic tuberculosis^ characterized by larger growths, which tend
to caseate and ulcerate. It may lead to perforation of the intestinal coils.
The exudate is purulent or sero-purulent, and is often sacculated.
(3) Clironic fibroid tuberculosis^ which may be subacute from the on-
set, or which may represent the final stage of an acute miliary eruption.
The tubercles are hard and pigmented. There is little or no exudation,
and the serous surfaces are matted together by adhesions.
The process may be primary and local, which was the case in five of
my seventeen post-mortems. In children the infection appears to pass
from the intestines, and in adults this is the source in the cases associated
with chronic phthisis. In women the disease extends commonly from
the Fallopian tubes. In at least 30 or 40 per cent of the instances of
laparotomy in this affection reported by gynsecologists the infection was
from them. The prostate or the seminal vesicles may be the starting-
point. In many cases the peritonaeum is involved with the pleura and
pericardium, particularly with the former membrane.
It is generally stated that males are attacked oftener than females.
In my own series of 21 cases, 15 were males. The recent laparotomies,
however, which have been performed in this disease have been chiefly in
females ; so that in the collected statistics I find the cases to be twice as
numerous in females as in males ; in the ratio, indeed, of 131 to 60.
Tuberculous peritonitis occurs at all ages. It is common in children
associated with intestinal and mesenteric disease. The incidence is most
frequent between the ages of twenty and forty. It may occur in advanced
life. In one of my cases the patient was eighty-two j^ears of age. Of
357 cases collected from the literature,* there were under ten years, 27 ;
between ten and twenty, 75 ; from twenty to thirt}^ 87 ; between thirty
and forty, 71 ; from forty to fifty, 61 ; from fifty to sixty, 19 ; from sixty
to seventy, 4 ; above seventy, 2. In America it is more common in the
negro than in the white race.
Symptoms. — In certain special features the tuberculous varies con-
siderably from other forms of peritonitis. It presents a symptom-complex
of extraordinary diversity.
In the first place, the process may be latent and not cause a single
symptom. Such are the cases met with accidentally in the operation for
* Johns Hopkins Hospital Reports, vol. ii.
23S SPECIFIC INFECTIOUS DISEASES.
hernia or for ovarian tumor. In direct contrast are the instances in which
the onset is so sudden and violent that the diagnosis of enteritis or hei'nia
is made. The operation for strangulated hernia has, indeed, been per-
formed. Many cases set in acutely with fever, abdominal tenderness, and
the symptoms of ordinary acute peritonitis. Cases with a slow onset,
abdominal tenderness, tympanites, and low continuous fever resemble
typlioid fever very closely, and may lead to error in diagnosis.
Ascites is frequent, but the effusion is rarely large. It is sometimes
hoemorrhagic. It may simulate the effusion in cirrhosis of the liver, of
which disease it is to be noted that tuberculous peritonitis is often a final
complication. Tymimnites may be present in the very acute cases, when
it is due to loss of tone in the intestines, owing to inflammatory infiltra-
tion ; or it may occur in the old, long-standing cases when universal
adhesion has taken place between the parietal and visceral layers. Fever
is a marked symptom in the acute cases, and the temperature may reach
103° or 104°. In many instances the fever is slight. In the more chronic
cases subnormal temperatures are common, and for days the temperature
may not rise above 97°, and the morning temperature may be as low as
95'5°. An occasional symptom is pigmentation of the skin, which in
some cases has led to the diagnosis of Addison's disease. A striking
peculiarity of tuberculous peritonitis is the frequency with which either
the condition simulates or is associated with tumor. These may be :
{a) Omental., due to puckering and rolling of this membrane until it
forms an elongated firm mass, attached to the transverse colon and lying
athwart the upper part of the abdomen. This cord-like structure is found
also with cancerous peritonitis, but is much more common in tubercu-
losis. Gairdner has called special attention to this form of tumor, and in
children has seen it undergo gradual resolution. A resonant percussion
note may sometimes be elicited above the mass. Though usually situated
in the umbilical region, the omental mass may form a prominent tumor
in the right iliac region.
(h) Sacculated exudation., in which the effusion is limited and confined
by adhesions between the coils, the parietal peritonaeum, the mesentery,
and the abdominal or pelvic organs. This encysted exudate is most
common in the middle zone, and has frequently been mistaken for ovarian
tumor. It may occupy the entire anterior portion of the peritonaeum, or
there may be a more limited saccular exudate on one side or the other.
It may lie completely within the pelvis proper, associated with tuberculous
disease of the Fallopian tubes.
(c) In rare cases the tumor formations may be due to great retraction
or thickening of the intestinal coils. The small intestine is found short-
ened, the walls enormously thickened, and the entire coil may form a firm
knot close against the spine, giving on examination the idea of a solid
mass. Not the small intestine only, but the entire bowel from the duode-
num to the rectum, has been found forming such a hard nodular tumor.
TUBERCULOSIS. 239
(d) Mesenteric glands^ which occasionally form very large, tumor-like
masses, more commonly found in children than in adults. This condition
may be confined to the abdominal glands. Ascites may coexist. The
condition must be distinguished from that in children, in which, with as-
cites or tympanites — sometimes both — there can be felt irregular nodular
masses, due to large caseous formations between the intestinal coils. No
doubt in a considerable number of cases of the so-called tabes mesenterica,
particularly in those with enlargement and hardness of the abdomen —
the condition which the French call carreau — there is involvement also of
the peritonaeum.
The diagnosis of these peritoneal tumors is sometimes very difficult.
The omental tumor is a less frequent source of error than any other ; but,
as already mentioned, a similar condition may occur in cancer. The most
important problem is the diagnosis of the saccular exudation from ovarian
tumor. In fully one third of the recorded cases of laparotomy in tuber-
culous peritonitis, the diagnosis of cystic ovarian disease had been made.
The most suggestive points for consideration are the history of the patient
and the evidence of old tuberculous lesions. The physical condition is
not of much moment, as in many instances the patients have been robust
and well nourished. Irregular febrile attacks, gastro-intestinal disturb-
ance, and pains are more common in tuberculous disease. Unless in-
flamed there is usually not much fever with ovarian cysts. The local
signs are very deceptive, and in certain cases have conformed in every
particular to those of cystic disease. The outlines in saccular exudation
are rarely so well defined. The position and form may be variable, owing
to alterations in the size of the coils of which in parts the walls are com-
posed. Nodular cheesy masses may sometimes be felt at the peripher3\
Depression of the vaginal wall is mentioned as occurring in enc3^sted peri-
tonitis ; but it is also found in ovarian tumor. Lastly, the condition of
the Fallopian tubes, of the lungs and of the pleurae, should be thoroughly
examined. The association of salpingitis with an ill-defined anomalous
mass in the abdomen should arouse suspicion, as should also involvement
of the pleura, the apex of one lung, or a testis in the male.
VI. Tuberculosis of the Alimentary Canal.
{a) Lips. — Tuberculosis of the lip is very rare. It occurs occasion-
ally in the form of an ulcer, either alone or more commonly in association
with laryngeal or pulmonary disease. Two cases are reported and the
literature analyzed in Verneuil's Etudes.* The ulcer is usually very sensi-
tive and may be mistaken for a chancre or an epithelioma. The diagnosis
may be made in cases of doubt by inoculation or the examination of a por-
tion for tubercle bacilli.
* Torae iii, Fas. 1.
2i0 SPECIFIC INFECTIOUS DISEASES.
(b) Tongue. — The disease begins by an aggregation of small granular
bodies on the edge or dorsum. Ulceration proceeds, leaving an irregular
sore with a distinct but uneven margin, and a rough, often caseous base.
The disease extends slowly and may form an ulcer of considerable size.
I have known it to be mistaken for epithelioma and the tongue to be
excised. It is rarely met with except when other organs are involved.
The glands of the angle of the jaw are not enlarged and the sore does not
yield to iodide of potassium, which are points of distinction between the
tuberculous and the syphilitic ulcer. In doubtful cases the inoculation
test should be made, or a portion excised for microscopical examination.
(c) Tubercles may develop on the hard or soft palate. In a recent
case under the care of my colleague Halsted there was a rough, irregular
patch on the roof of the mouth, grayish in spots, and fissured.
(d) Tuberculosis of the tonsil has been recorded in a few cases, either
in the form of the miliary granules or as caseous foci. Ulceration may
occur. In the acute cases the submaxillary glands may be enlarged.
(e) Pliary7ix. — In extensive laryngeal tuberculosis an eruption of
miliary granules on the posterior wall of the pharynx is not very uncom-
mon. In chronic phthisis an ulcerative pharyngitis, due to extension of
the disease from the epiglottis and larynx, is one of the most distressing
of complications, rendering deglutition acutely painful.
(/) A few instances occur in literature of tuberculosis of the msopha-
gus. The condition is a pathological curiosity, except in the slight exten-
sion from the larynx, which is not infrequent.
{g) Stomach. — Many cases are reported which are doubtful. Primary
disease is unknown. Marfan* was able to collect only about a dozen
authentic cases. Perforation of stomach occurred six times, thrice by a
tuberculous gland. In Oppolzer's case an ulcer of the colon perforated
the organ. In Musser's case there was a large tuberculous ulcer three by
one and a half inches in extent.
{h) Intestines. — The tubercles may be (1) primary in the mucous
membrane, or more commonly (2) secondary to disease of the lungs, or in
rare cases the affection may (3) pass from the peritonaeum.
(1) Primary intestinal tuberculosis occurs most frequently in children,
in whom it may be associated with enlargement and caseation of the
mesenteric glands, or with peritonitis. It may be difficult to say at the
time of the autopsy whether the primary lesion has been intestinal or
peritoneal. I have already referred to Woodhead's statistics showing the
remarkable frequency of infection through the bowel. In adults primary
intestinal tuberculosis is rare ; but now and then cases occur in which the
disease sets in with irregular diarrhoea, moderate fever, and colicky pains.
In a few cases haemorrhage has been the initial symptom. Regarded at
first as a chronic catarrh, it is not until the emaciation becomes marked or
* Paris Thesis, 1887.
TUBERCULOSIS. 241
the signs of disease appear in tlie lungs that tlie true nature is apparent.
Still more decc})tive are the cases in which the tuberculosis begins in the
ca3cum and there are symptoms of typhlitis — tenderness in the right iliac
fossa, constipation, or an irregular diarrhoea and fever. These signs may
gradually disappear, to recur again in a few weeks, and still further com-
plicate the diagnosis. Perforation may occur with the formation of a
pericaecal abscess, or perforation into the peritona3um may take place, or
in very rare instances there is partial healing with great thickening of the
walls and narrowing of the lumen.
(2) Secondary involvement of the bowels is very common in chronic
pulmonary tuberculosis. The lesions are chiefly in the ileum, caecum, and
colon. The affection begins in the solitary and agminated glands or on
the surface of or within the mucosa. The caseation and necrosis lead to
ulceration, which may be very extensive and involve the greater portion of
the mucosa of the large and small bowels. In the ileum the Peyer's
patches are chiefly involved and the ulcer may be ovoid, but in the
jejunum and colon the ulcers are usually round or transverse to the
long axis. The tuberculous ulcer has the following characters : (a) It is
irregular, rarely ovoid or in the long axis, more frequently girdling the
bowel, (b) The edges and base are infiltrated, often caseous. ((•) The
submucosa and muscularis are usually involved ; and (d) on the serosa
may be seen colonies of young tubercles or a well-marked tuberculous
lymphangitis. Perforation and peritonitis are not uncommon events in
the secondary ulceration. Stenosis of the bowel from cicatrization may
occur; the strictures may be multiple.
Tuberculosis of the rectum has a special interest in connection with
fistula in ano, which, according to Spill man's statistics, occurs in about
3"5 per cent of cases of pulmonary disease. In many instances the
lesion has been shown to be tuberculous. It is very rarely primary, but
if the tissue on removal contains bacilli and is infective the lungs are
almost invariably found to be involved. It is a common opinion that the
pulmonary symptoms may develop rapidly after the fistula is cut. This
may have some basis if the operation consists in laying the tract open,
and not in a free excision.
(3) Extension from the peritonaeum may excite tuberculous disease in
the bowels. The affection may be primary in the peritonaeum or extend
from the tubes in women or the mesenteric glands in children. The coils
of intestines become matted together, caseous and suppurating foci de-
velop between the folds, and perforation may take place between the coils
at several different places.
242 SPECIFIC INFECTIOUS DISEASES.
VII. Tuberculosis of the Liver.
This organ is very constantly involved in (a) general tuberculosis.
The miliary granulation may be very small and in acute cases scarcely
perceptible. The liver is pale and often fatty.
(b) A remarkable condition of the organ is produced by the develop-
ment of the tubercles in the finer bile-vessels. They may attain a con-
siderable size and are almost always softened in the centre, resembling
small abscesses. The contents are always bile-stained. The organ may
be honeycombed with these tuberculous abscesses.
(c) Large, coarse caseous masses are occasionally found, sometimes in
association with perihepatitis or tuberculous peritonitis. They may attain
the size of an orange or larger.
{(I) Tuberculous cirrhosis. With the eruption of miliary tubercles
there may be slight increase in the connective tissue, which is over-
shadowed by the fatty change. In all the chronic forms of tubercle in
this organ there may be fibrous overgrowth. Ilanot, who has described
several varieties, states that the condition may be primary. Practically it
is very rare, except in connection with chronic tuberculous peritonitis and
perihepatitis, wdien the organ may be much deformed by a sclerosis in-
volving the portal canals.
In this last group there may be symptoms of ascites ; as a rule, tuber-
culosis of the liver has a purely anatomical interest.
VIII. Tuberculosis of the Brain and Cord.
Tuberculosis of the braiii occurs as (a) an acute miliary infection caus-
ing meningitis and acute hydrocephalus; (b) as a chronic meningo-en-
cephalitis, usually localized, and containing small nodular tubercles ; and
(c) as the so-called solitary tubercle. Between the last two forms there
are all gradations, and it is rare to see the meninges uninvolved. The
acute variety has already been considered. I shall here consider the
chronic form, which develops slowly and has the clinical characters of a
tumor.
It is most common in the young. Of 148 cases collected by Pribram
118 were under fifteen years of age. Other organs are usually involved,
particularly the lungs, the bronchial glands, or the bones. In rare in-
stances no tubercles are found elsewhere. They occur most frequently in
the cerebellum ; next in the cerebrum and then in the pons. The growths
are often multiple, in 100 out of 183 cases (Gowers). They range in size
from a pea to a walnut; larger tumors occasionally occur, and sometimes
an entire lobe of the cerebellum is affected. On section the tubercle pre-
sents a grayish-yellow, caseous appearance, usually firm and hard, and en-
circled by a translucent, softer tissue. Tlie centre of tlie growth may be
semi-difHuent. As in other localities the tubercle may calcify. The tu-
TUBERCULOSIS. 243
•
mors are as a rule attached to the meninges, often to tlie pia at tlie bottom
of a sulcus so that they look imbedded in the brain-substance. About the
longitudinal fissure there may be an aggregation of the growths, with
compression of the sinus, and the formation of a thrombus. The tuber-
culous tumor not infrequently excites acute meningitis. In localized
meningo-encephalitis the pia is thickened, tubercles are adherent to the
under surface and grow about the arteries. It is often combined with
cerebral softening from interference with the circulation. Several of the
most characteristic instances which I have seen were on the meninges
covering the insula. This form may develop in pulmonary tuberculosis,
causing hemiplegia or aphasia which may persist for months.
The symptoms of tuberculous growths in the brain are those of tumor,
and will be considered in the section on the brain.
In the spi7ial cord the same forms are found. The acute tuberculous
meningitis has been considered and is almost always cerebro-spinal. The
solitary tubercle of the cord is rare. Herter has reported three cases and
collected twenty-four instances from the literature. It was seco'ndary in
all save one case. The symptoms are those of spinal tumor or meningitis.
IX. Tuberculosis of the Genito-urinary System.
{a) Tuberculosis of the Kidneys (Phthisis renum). — In general tuber-
culosis the kidneys frequently present scattered miliary tubercles. In pul-
monary tuberculosis it is common to find a few nodules in the substance
of the organ, or there may be pyelitis. Primary tuberculosis of the kid-
neys is not very rare. In a majority of the cases the process involves the
pelvis and the ureter as well, sometimes the bladder and prostate. In only
one of eight cases was the prostate involved. It may be difficult to say in
advanced cases whether the disease has started in the bladder, prostate, or
vesicles, and crept up the ureters, or whether it started in the kidneys and
proceeded downward. In a majority of cases it is, I believe, the latter,
and the infection is through the blood. One kidney alone may be in-
volved, and the disease creeps down the ureter and may only extend a
few millimetres on the vesical mucosa. In a recent instance a man with
aortic insufficiency, who had no lesions in the lungs, presented a localized
patch in the pelvis, involving a pyramid, while the ureter, five centimetres
from the bladder and at its orifice, was thickened and tuberculous. The
prostate showed an area of caseation. It is most common in the middle
period of life, but it may occur at the extremes of age. It is more fre-
quent in men than in women. In the earliest stage, which may be met
with accidentally, the disease is seen to begin in the pyramids and calyces.
Necrosis and caseation proceed rapidly, and the colonies of tubercles start
throughout the pyramids and extend upon the mucous membrane of the
pelvis. As a rule, from the outset, it is a tuberculous pyo-nephrosis. The
disease may be confined to one kidney, or progress more extensively in
24:4: SPECIFIC INFECTIOUS DISEASES.
•
one than in the other. At autopsy both organs are usually found enlarged.
One organ may be completely destroyed and converted into a series of cysts
containing cheesy substance ; a form of kidney which the older writers
called scrofulous. In the putty-like contents of these cysts lime salts may
be deposited. In other instances the walls of the pelvis are thickened and
cheesy, the pyramids eroded, and caseous nodules are scattered through
the organ, even to the capsule, which may be thickened and adherent.
The other organ is usually less affected, and shows only pyelitis or a super-
ficial necrosis of one or two pyramids. The ureters are usually thickened
and the mucous membrane ulcerated and caseous. Involvement of the
bladder, vesiculae seminales, and testes is not uncommon in males.
The symptoms are those of pyelitis. The urine may be purulent for
years, and there may be little or no distress. When the bladder becomes
involved micturition is frequent, and many instances are mistaken for cys-
titis. The condition is for many years compatible with fair health. The
curability is shown by the accidental discovery of the so-called scrofulous
kidney, converted into cysts containing a putty-like substance. In cases
in which the disease becomes advanced and both organs are affected, con-
stitutional symptoms are more marked. There is irregular fever, with
chills, and loss of weight and strength. General tuberculosis is common.
In only one of my cases were the lungs uninvolved. In a case at tlie
Montreal General Hospital a cyst perforated and caused fatal peritonitis.
Physical examination may detect special tenderness on one side, or the
kidney may be palpable in front on deep pressure ; but tuberculous pyelo-
nephritis seldom causes a large tumor. Occasionally the pelvis becomes
enormously distended ; but this is rare in comparison with calculous
pyelitis. The urine presents changes similar to those of ordinary calcu-
lous pyelitis — pus-cells, epithelium, and occasionally definite caseous
masses. Albumen is, of course, present. Tubercle bacilli may be demon-
strated by the ordinary methods. Tube-casts are not often seen.
To distinguish the condition from calculous pyelitis is often difficult.
Haemorrhage may be present in both, though not nearly so frequently in
the tuberculous disease. Careful examination of the pus for tubercle
bacilli gives most important information. The lungs or other organs may
be tuberculous.
Tlie incidence of renal in uro-genital tuberculosis may be gathered
from Orth's Gottingen material, analyzed by Oppenheim. Of 60 cases
there wore 34 in whioh tlic kidneys were involved.
(h) Tuberculosis of the Ureters and Bladder. — Tliis rarely occurs as
a primary affection, hut is nearly jdways secondary to involvement of other
parts, particularly the pelvis of the kidney. In the case of uro-genital
tuberculosis, above mentioned, in a patient who died of heart disease, the
ureter, just where it enters the bladder, showed a fresh patch of tuber-
culosis.
Protracted cystitis, which has come on without apparent cause, is
TUBERCULOSIS. 245
always suggestive of tuberculosis. The renal regions, the testes, and tlie
prostate should be examined with care. It may follow a pyelo-ncphritis
or be associated with primary disease of the prostate or vesiculae scmi-
nales.
(c) Tuberculosis of the Prostate and VesiculsB Seminales. — The pros-
tate is frequently involved in tuberculosis of the uro-genital tract. In
Krzyincki's cases, of 15 males the prostate was involved in 14 and the ve-
siculse seminales in 11. In Orth's cases the prostate Was involved in 18
of the 37 cases in males. These parts are much more frequently involved
than ordinary post-mortem statistics indicate.
(d) Tuberculosis of the Testes. — This somewhat common affection
may be primary, or, more frequently, is secondary to tuberculous disease
elsew^here. Many cases occur before the second year, and it is stated to
have been met with in the foetus. In infants it is serious and usually
associated with tuberculous disease in other parts. In nine cases recently
reported by Hutinel and Deschamps * in every one there was a general
affection. In 20 cases reported by Jullien f 6 were under one year, and G
between one and two years old. In five of the cases both testicles were
affected. Koplik holds that most of the cases of this kind are congenital,
in Baumgarten's sense. In the adult the tubercles begin within the sub-
stance of the gland, but in children the tunica albuginea is first affected.
The tubercle does not always undergo caseation, but it may present a
number of embryonic cells, not unlike a sarcoma.
Tubercle of the testes is most likely to be confounded w^ith syphilis.
In the latter the bodv of the ors^an is most often affected, there is less
pain, and the outlines of the growth are more nodular and irregular. In
obscure peritoneal disease the detection of tubercle in a testis has not
infrequently led to a correct diagnosis. The association of the two con-
ditions is not uncommon. The lesion in the testis may heal completely,
or the disease may become generalized. General infection has followed
operation.
(e) Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus. — The
special attention which has been paid to local affections of these parts by
gynaecologists has taught us that primary tuberculosis of the tubes is not
at all uncommon. Within a year my colleague, Kelly, has operated upon
five or six cases. The disease may be primary and produce a most char-
acteristic form of salpingitis, in which the tubes are enlarged, the walls
thickened and infiltrated, and the contents cheesy. Adhesion takes phice
between the fimbriae and the ovaries, or the uterus may be invaded. The
condition is usually bilateral. It may occur in young children. Although,
as a rule, very evident to the naked eye, there are specimens resembling
ordinary salpingitis, which show on microscopical examination numerous
miliary tubercles (Welch and AVilliams). Tuberculous salpingitis may
* Archives Generales de Medccine, 1891. f Ibid., 1890.
216 SPECIFIC INFECTIOUS DISEASES.
cause serious local disease with abscess formation, and it may be the
starting-point of peritonitis.
Tuberculosis of the uterus is very rare. Only three examples have
come under my observation, all in connection with pulmonary phthisis.
It may be primary. The mucosa of the fundus is thickened and caseous,
and tubercles may be seen in the muscular tissue. Occasionally the pro-
cess extends to the vagina.
X. Arteries.
Primary tuberculosis of the larger blood-vessels is unknown. The dis-
ease may, however, occur in a large artery and not result from external
invasion. In a case of chronic phthisis from my ward Councilman found
a fresh tuberculous growth in the aorta, which had no connection with
cheesy masses outside the vessel.
In the lungs and other organs attacked by tuberculosis the arteries are
involved in an acute infiltration which usually leads to thrombosis, or
tubercles may develop in the walls and proceed to caseation and softening
frequently with the result of haemorrhage. By extension into vessels,
particularly veins, the bacilli are widely distributed. In meningitis tuber-
culosis of the arteries plays an important role.
XI. The Prognosis in^ Tuberculosis.
Not all persons in whose bodies the bacilli gain a foothold present
marked signs of tuberculosis. As will be stated in the next section, local
disease is found in a considerable number of all cadavers. Infection does
not necessarily mean the establishment of a progressive and fatal disease.
In my autopsies, excluding cases dead of pulmonary phthisis, 7"5 per cent
presented tuberculous lesions of the lungs — a low percentage in compari-
son with other records, as I carefully excluded the simple fibroid pucker-
ing at the apex and the solitary cheesy nodule, unless surrounded by colo-
nies of tubercles.
In many cases a natural or spontaneous cure is effected, for the condi-
tions favorable to the development of the disease are not present — in
other words, the tissue-soil is unsuitable. Apart from this group, a ma-
jority of which probably do not show any sign of disease, there may be
spontaneous arrest after the symptoms have become decided. Many years
ago Flint called attention to the self-limitation and intrinsic tendency to
recovery in well-marked pulmonary tuberculosis. Of his G70 cases, 44 re-
covered, and in 31 the disease was arrested, spontaneously in 23 of the
first group and in 15 of the second. This natural tendency to cure is
still more strikingly shown in lymphatic and bone tuberculosis.
The following may be considered favorable circumstances in the prog-
nosis of pulmonary tuberculosis : A good family history, previous good
health, a strong digestion, a suitable environment, and an insidious onset,
TUBERCULOSIS. 247
without high fever, and without extensive pneumonic consolidation. Cases
beginning with ])lcurisy seem to run a more protracted and more favorable
course. Eepeated attacks of haemoptysis are unfavorable. When well
established the course of tuberculosis in any organ is marked by intervals
of weeks or months in which the fever lessens, the symptoms subside, and
there is improvement in the general health.
In pulmonary cases the duration is extremely variable. Laennec placed
the average duration at two years, and for the majority of cases this is
perhaps a correct estimate. Pollock's large statistics of over 3,500 cases
shows a mean duration of the disease of over two years and a half. Will-
iams's analysis of 1,000 cases in private practice shows a much more pro-
tracted course^ as the average duration was over seven years.
Under the subject of prognosis comes the question of the marriage of
persons wdio have had tuberculosis, or in whose family the disease prevails.
The following brief statements may be made with reference to it :
(a) Subjects with healed lymphatic or bone tuberculosis marry with
personal impunity and may beget healthy children. It is undeniable, how-
ever, that in such families, scrofula, caries of the bone, arthritis, cerebral
and pulmonary tuberculosis are more common. Which is it, " heredite
de graine ou heredite de terrain," as the French have it, the seed or the
soil, or both ? We cannot yet say. The risks, however, are such as may
properly be taken.
(b) The question of marriage of a person who has arrested or cured
lung tuberculosis is more difficult to decide. If a male, the personal risk
is not so great ; and when the health and strength are good, the external
environment favorable, and the family history not extremely bad, the
experiment — for it is such — is often successful, and many healthy and
happy families are begotten under these circumstances. In women the
question is complicated with that of child-bearing, which increases the
risks enormously. With a localized lesion, absence of hereditary taint,
good physique, and favorable environment, marriage might be permitted.
When tuberculosis has existed, however, in a girl whose family history is
bad, whose chest expansion is slight, and w^hose physique is below the
standard, the physician should, if possible, place his veto upon marriage.
(c) With existing disease, fever, bacilli, etc., marriage should be abso-
lutely prohibited. Pregnancy and parturition hasten the process in almost
every case. There is much truth, indeed, in the remark of Dubois : " If
a woman threatened with phthisis marries, she may bear the first ac-
couchement well ; a second, with difficulty ; a third, never."
XII. Prophylaxis in Tuberculosis.
(a) General. — The sputa of phthisical patients should be carefully col-
lected and destroyed. Patients should be urged not to spit about care-
lessly, but always to use a spit-cup. Several forms of portable flasks have
17
248 SPECIFIC INFECTIOUS DISEASES.
been devised and are now on sale. The destruction of the sputa of con-
sumptives should be a routine measure in both hospital and private prac-
tice. Thorough boiling or putting it into the fire is sufficient. It should
be explained to the patient that the only risk, practically, is from this
source. The chances of infection are greater in young children. The
nursing and care of consumptives involve very slight risks indeed if
proper precautions are taken. The patient should occupy a single bed.
A second important general prophylactic measure relates to the in-
spection of dairies and slaughter-houses. The possibility of the transmis-
sion of tuberculosis by infected milk has been fully demonstrated, and in
the interest of public health the state should take measures to stamp out
tuberculosis in cattle. Systematic veterinary inspection of dairies, par-
ticularly in the large cities, should be made, and full power granted to
confiscate and kill suspected animals. The abattoirs should be under
skilled veterinary control, and the carcasses of animals with advanced
tuberculosis confiscated. There is, however, much less danger of infection
through meat than through milk.
(b) Individual. — A mother with pulmonary tuberculosis should not
suckle her child. An infant born of tuberculous parents, or of a family
in which consumption prevails, should be brought up with the greatest
care and guarded most particularly against catarrhal affections of all
kinds. Special attention should be given to the throat and nose, and on
the first indication of mouth-breathing, or any obstruction of the naso-
pharynx, a careful examination should be made for adenoid vegetations.
The child should be clad in flannel and live in the open air as much as
possible, avoiding close rooms. It is a good practice to sponge the throat
and chest night and morning with cold water. Special attention should
be paid to diet and to the mode of feeding. The meals should be at regu-
lar hours and the food plain and substantial. From the outset the child
should be encouraged to drink freely of milk. Unfortunately, in these
cases there seems to be an uncontrollable aversion to fats of all kinds.
As the child grows older, systematically regulated exercise or a course
of pulmonary gymnastics may be taken. In the choice of an occupa-
tion preference should be given to an out-of-door life. Families with a
marked predisposition to tuberculosis should, if possible, reside in an
equable climate. It would be best for a 3^oung man belonging to such
a family to remove to Colorado or southern California, or to some other
suitable climate, before trouble begins.
The trifling ailments of children should be carefully watched. In the
convalescence from the fevers, which so frequently prove dangerous, the
greatest caution should be exercised to prevent catching cold. Cod-liver
oil, the syrup of iodide of iron, and arsenic may be given. As mentioned,
care of the throat in these children is very important. When the tonsils
are chronically enlarged they should be removed.
TUBEliCULOSIS. 249
XIII. Treatment of Tuberculosis.
I. The Natural or Spontaneous Cure. — The spontaneous healing of
local tuberculosis is an every-day afl'air. Many cases of adenitis and dis-
ease of the bone or of the joints terminate favorably without the aid of
medicines. The healing of pulmonary tuberculosis is shown clinically by
the recovery of patients in whose sputa elastic tissue and bacilli have been
found ; anatomically, by the presence of lesions in all stages of repair. In
the granulation products and associated pneumonia a scar-tissue is formed,
while the smaller caseous areas become impregnated with lime salts. To
such conditions alone should the term healing be applied. AVhen the
fibroid change encapsulates but does not involve the entire tuberculous
tissue, the tubercle may be termed involuted or quiescent, but is not de-
stroyed. When cavities of any size have formed, healing, in the proper
sense of the term, does not occur. I have yet to see a specimen which
would indicate that a vomica had cicatrized. Cavities may be greatly
reduced in size — indeed, an entire series of cavities may be so contracted
by sclerosis of the tissue about them that an upper lobe, in which this
process most frequently occurs, may be reduced to a third of its ordinary
dimensions. Laennec understood thoroughly this natural process of cure
in tuberculosis, and recognized the frequency with which old tuberculous
lesions occurred in the lungs. He described cicatrices completes and cica-
trices fistuleuses^ the latter being the shrunken cavities communicating
with the bronchi ; and suggested that, as tubercles growing in the glands,
which are called scrofula, often heal, why should not the same take place
in the lungs?
There is an old German axiom, '•'' Jedermann hat am Ende ein hischen
Tuberciilose^'' a statement partly borne out by the statistics showing the
proportion of cases in persons dying of all diseases in whom quiescent or
tuberculous lesions are found in the lungs. AYe find at the apices the
following conditions, which have been held to signify healed tuberculous
processes : (1) Thickening of the pleura, usually at the posterior surface
of the apex, with subadjacent induration for a distance of a few milli-
metres. This has, perhaps, no greater significance than the milky patch
on the pericardium. (2) Puckered cicatrices at the apex, depressing the
pleura, and on section showing a large pigmented, fibrous scar. The
bronchioles in the neighborhood may be dilated, but there are neither
tubercles nor cheesy masses. This may sometimes, but not always, indi-
cate a healed tuberculous lesion. (3) Puckered cicatrices with cheesy or
cretaceous nodules, and with scattered tubercles in the vicinity. (4) The
cicatrices fistuleuses of Laennec, in which the fibroid puckering has re-
duced the size of one or more cavities which communicate directly with
the bronchi.
In 1,000 autopsies, excluding the 216 cases dead of phthisis, there were
50 cases (7'5 per cent) which presented undoubted tuberculous lesions in
250 SPECIFIC INFECTIOUS DISEASES.
the Inngs. I excluded the simple fibroid puckering and the solitary cheesy
nodules, unless, in the latter case, there were colonies of tubercles in the
vicinity. These 59 cases died of various diseases and at various ages. A
majority of them were between forty and sixtV; My experience tallies
closely with the larger analysis made by Heitler of the Vienna post-mortem
records, in which, of 16,562 cases in which the death was not directly caused
by phthisis, there were 780 instances of obsolete tubercle — a percentage oi
4*7. He excluded, as I have done, the simple fibroid induration. Vari-
ous observations have been made of late in which the percentage ranges
from twenty-seven (Bollinger) to thirty-nine (Massini). In 200 autopsies,
in which this point was specially examined, Harris found 38"8 per cent in
which there were relics of former active tuberculosis. The statement is
made by Bouchard that, of the post-mortems at the Paris morgue — gen-
erally upon persons dying suddenly — the percentage found with some
evidence of tuberculous lesion, active or obsolete, is as high as seventy- five.
These figures show the extraordinary frequency of pulmonary infection
and the encouraging fact that in so large a percentage the disease remains
local and undergoes a process of arrest or healing.
II. General Measures. — There are three indications — first, to place the
patient in surroundings most favorable for the maintenance of a maximum
degree of nutrition ; second, to take such measures as, in a local or general
way, influence the tuberculous processes ; third, to alleviate symptoms.
The question of environment is of first importance in the treatment
of tuberculosis. It is illustrated in an interesting and practical way by an
experiment of Trudeau, showing that inoculated rabbits, confined in a
dark, damp place, rapidly succumb, while others, allowed to run wild,
either recover or show slight lesions. It is the same in human tubercu-
losis. A patient confined to the house — particularly in the close, over-
heated, stuffy dwellings of the poor, or treated in a hospital ward — is
in a position analogous to the rabbit confined to a hutch in the cellar ;
wliereas a patient living in the fresh air and sunshine for the greater
part of the day has chances comparable to those of the rabbit running
wild.
In the majority of cases the treatment has to be carried out at home
and often under adverse conditions. Still, much can be done if the patient
is kept out of doors in the fresh air for the greater part of each day. In
pulmonary tuberculosis neither the coucjh^ the fevei\ the iiight-sicents, nor
the hiemoptyns contra-indicates this rule. Only when the weather is
blustering or rainy should the patient remain in the house. It is remark-
able how quickly improvement in many instances follows this fresh-air
treatment. In cities the patient can be wrapped up and placed on a sofa
or in a reclining-chair on tlie balcony or even in the yard.
Tlie climatic treatment of tuberculosis is simply a modification of this
plan. The requirements of a suitable climate are a j'jf^re atmosphere^
an equable temperature not subject to rapid variations, and a maximum
TUBERCULOSIS. 251
amount of simshine. Given these three factors, and it makes little differ-
ence luhere a patient goes so long as he lives an outdoor life.
The purity of the atmosphere is the first consideration, and it is tliis
requirement tliat is met so well in the mountains and forests. Altitude is
a secondary consideration. The rarefaction of the air in high altitudes is
of benefit in increasing the respiratory movements in pulmonary disease,
but brings about in time a condition of dilatation of the air- vesicles and a
permanent increase in the size of the chest which is a marked disadvan-
tage when such persons attempt subsequently to reside at the sea-level.
The temperature of the air is also a minor consideration, so long as it
is tolerably equable and not subject to rapid variations. The winter cli-
mates of the Adirondacks, of Colorado, or of Davos have the advantage of
a steady cold combined with sunshine, just as the resorts of the Southern
States and California, and of the south of France and Italy, have a tolerably
uniform high temperature with the maximum amount of sunshine. The
dryness of the air is certainly an important though not an essential factor.
That it is not essential is seen in the good results obtained in the resorts
at the sea-level, such as Florida, or even Torquay or Falmouth, on the
south coast of England — one of the most humid atmospheres in the world.
Other considerations which should influence the choice of a locality
are good accommodations and good food. Very much is said concerning
the choice of locality in the different stages of pulmonary tuberculosis,
but when the disease is limited to an apex, in a man of fairly good personal
and family history, the chances are that he may fight a winning battle if
he lives out of doors in any climate, whether high, dry, and cold or low,
moist, and warm. With bilateral disease and cavity formation there is but
little hope of permanent cure, and the mild or warm climates are preferable.
AVhether a patient should go from home or not is a grave question
which the physician is called upon to decide. It is undoubtedly, in
many instances, a positive hardship to send away a patient with tolerably
advanced tuberculosis. With well-marked cavities, hectic fever, night-
sweats, and emaciation he is better at home, and the physician should not
be too much influenced by the importunities of the patient or his friends.
Advanced cases and persons with feeble hearts should never be sent to high
altitudes. Of American resorts I prefer the Adirondacks for early cases.
The patient should go in October, so as to become gradually accustomed
to the cold. It is accessible, the winter climate is admirable, and the
camp-life delightful. As the reports of Saranac Sanitarium show, recent
tuberculosis does remarkably well. Personally I have seen better results
from the Adirondacks than from any other place. Colorado and southern
California have this advantage for early cases — they are progressive, pros-
perous countries in which a man may find means of livelihood and live
in comfort.*
On the question of climate, Yeo's work may be consulted with advantage.
252 SPECIFIC INFECTIOUS DISEASES.
Under this section reference may be made to the question of the treat-
ment of tuberculosis in sanitaria. The larger cities should build special
institutions within easy access by railway, with pleasant surroundings, in
which early cases of pulmonary tuberculosis among the poor could be
systematically treated. Advanced cases should not be admitted, but should
be cared for in separate wards of the city hospitals. Sanitaria for the care
of recent pulmonary tuberculosis among the well-to-do classes are also
urgently needed. The results obtained at Falkenstein near Frankfurt
a. M. (which certainly has nothing special, as far as climate is concerned)
and at the Saranac Sanitarium illustrate how much can be done by method
and care.
III. Measures which, by their Local or General Action, influence the
Tuberculous Process. — Under this heading we may consider the specific,
the dietetic, and the general medicinal treatment of tuberculosis.
(a) The Specific Treatment. — A glycerin extract of the cultures of
tubercle bacilli was found by Koch to have a specific action upon tubercu-
lous tissue. The influence of this tuberculin, as it is called, is best seen
in lupus, upon which it exercises an extraordinary effect, unique in the
history of the action of remedies. An injection of one milligramme is
followed, in a few hours, by intense constitutional and local reaction.
The affected tissues swell enormously, and the adjacent parts are deeply
congested. Crusts form upon the surface, the swelling and inflammation
gradually subside, and after several injections the lupus masses gradually
disappear and are replaced by a white cicatricial tissue. Even in advanced
cases of long duration the action is, in a majority of cases, prompt and
beneficial. There is a great difficulty, however, in getting rid of the final
remnants of the lupus tissue, and a combination of scraping with the
tuberculin will probably always be needed.
In internal tuberculosis the remedy, in very early cases, may, as shown
by Koch's reports, prove actually curative ; unfortunately, it was employed
in all classes of cases. In pulmonary tuberculosis it is a remedy to be used
with the greatest caution. Of twenty-three cases in which we have used
it at the Johns Hopkins Hospital, only three were benefited ; in the others
the action was either negative or actually detrimental. It should not be
employed in cases with fever or with much consolidation. In many cases
it seems to aggravate the general and local symptoms.
AVe are at present in the reaction wave, after being buoyed up by
hopes that at last a remedy had been obtained which was positively cura-
tive in all forms of tuberculous lesions. It will probably be several years
before we can speak with decision upon the true position of this remedy.
Meanwhile our knowledge warrants us in urging extreme caution in its
use. The recent reports of Schede indicate that the remedy has a very
positive value in tuberculous arthritis when combined with other meas-
ures.
(h) Dietetic Treatment. — The outlook in tuberculosis depends much
TUBERCULOSIS. 253
upon the digestion. It is rare to see recovery in a case in which there is
persistent gastric trouble, and the physician should ever bear in mind the
fact that in this disease ilia primce vim control the position. The early
nausea and loss of appetite in many "cases of phthisis are serious obstacles.
Many patients loathe food of all kinds. A change of air, or a sea voyage
will promptly restore the appetite. When this is impossible, and if, as is
almost always the case, fever is present, the patient should be placed at
rest, kept in the open air nearly all day, and fed at stated intervals with
small quantities either of milk, buttermilk, or koumyss, alternating if
necessary with meat juice and Qgg albumen. Some cases which are
disturbed by eggs and milk do well on koumyss. It may be necessary
to resort to Debove's method of over-alimentation or forced feeding. The
stomach is first washed out with cold water, and then, through the tube,
a mixture is given containing a litre of milk, an egg^ and one hundred
grammes of very finely powdered meat. This is given three times a day.
Sometimes the patients will take this mixture without the unpleasant ne-
cessity of the stomach-tube, in which case a smaller amount may be given.
I can speak of the advantage of this plan in cases in which the gastric
symptoms have been obstinate and distressing, and the general expression
of opinion is, in such instances, very favorable to this plan of treatment.
In many cases the digestion is not at all disturbed and the patient can
take an ordinary diet. It is remarkable how rapidly the appetite and
digestion improve on the fresh-air treatment, even in cases which have
to remain in the city. Care should be taken that the medicines do not
disturb the stomach. Xot infrequently the sweet syrups used in the
cough mixtures, cod-liver oil, creasote, and the hypophosphites produce
irritation, and by interfering with digestion do more harm than good.
On the other hand, the bitter tonics, with acids, and the various malt
preparations are often in these cases most satisfactory. The indications
for alcohol in tuberculosis are enfeebled digestion with fever, a weak
heart, and rapid pulse. A routine administration is not advisable, and
there is no evidence that its persistent use promotes fibroid processes in
the tuberculous areas. In the advanced stages, particularly when the
temperature is low between eight and ten in the morning, whisky and
milk, or whisky, Qgg^ and milk may be given with great advantage. The
red wines are also beneficial in moderate quantities.
(c) General Medical Treatmeyit. — No medicinal agents have any special
or peculiar action upon tuberculous processes. The influence which they
exert is upon the general nutrition, increasing the physiological resist-
ance and rendering the tissues less susceptible to invasion. The fol-
lowing are the most important remedies which seem to act in this
manner :
Creasote^ which may be administered in capsules, in increasing doses,
beginning with one minim three times a day and, if well borne, increas-
ing the dose to eight or ten minims. It may also be given in solution
25i SPECIFIC INFECTIOUS DISEASES.
with tincture of cardamom and alcohol. It is an old remedy, strongly
recommended by Addison, and the reports of Jaccoud, Fraentzel, and
many others show that it has a positive value in the disease. Guaiacol
may be given as a substitute, either internally or hypodermically. In 101
cases in which it was used at my clinic, by Meredith Keese, the chief
action was on the cough and expectoration, which were much lessened, but
the remedy had no essential influence on the progress of the disease.
Cod-liver Oil. — In glandular and bone tuberculosis, this remedy is
undoubtedly beneficial in improving the nutrition. In pulmonary tuber-
culosis its action is less certain, and it is scarcely worthy of the unbounded
confidence which it enjoyed for so many years. It should be given in
small doses, not more than a teaspoonful three times a day after meals.
It seems to act better in children than in adults. When it is not well
borne, a dessertspoonful of rich cream three times a day is an excellent
substitute. The clotted or Devonshire cream is preferable.
The Hypophosphites. — These in various forms are useful tonics, but
it is doubtful if they have any other action. They certainly exercise no
specific influence upon tubercle. They may be given in the form of the
syrup of the hypophosphites of calcium, sodium, and potassium of the
U. S. P.
Arsenic. — There is no general tonic more satisfactory in cases of tuber-
culosis of all kinds than Fowler's solution. It may be given in five-minim
doses three times a day and gradually increased ; stopping its use when-
ever unpleasant symptoms arise, and in any case intermitting it every
third or fourth week.
One or two special methods of dealing with pulmonary tuberculosis
may here be mentioned. The local treatment, by direct injection into the
lungs, has been practised since its strong advocacy by Pepper. It has,
however, not gained the general support of the profession, and is occa-
sionally followed by serious results. As a rule, it may be practised with
impunity, and the injections may be made with a long hypodermic
needle into any portion of the lung which is diseased. Iodine, carbolic
acid, creasote (three per cent solution in almond oil), and iodoform have
been used for the purpose. The remarkable results which surgeons have
recently obtained in the treatment of joint tuberculosis by injections of
iodoform point to this as a remedy which will probably prove of service
when injected directly into the lungs.
Treatment by compressed air is in many cases beneficial, and under
its use the appetite improves, there is gain in weight, and reduction of the
fever. The air may be saturated with creasote.
IV. Treatment of Special Symptoms in Pulmonary Tuberculosis. — {n)
The Fever. — There is no more difficult problem in practical therapeutics
than the treatment of the pyrexia of tuberculosis, Tlie patient should be
at rest, and when practicable wheeled into tlie fresh air for as long a time
as possible during the day. Fever does not contra-indicate an out-of-door
TUBERCULOSIS. 255
life, but it is well for patients with a temperature above 101° or 102° to
be at rest. For the continuous pyrexia or the remittent type of the early
stages, quinine, small doses of digitalis, and the salicylates may b6 tried ;
but they are uncertain and rarely reliable. Under no circumstances is
that priceless remedy, quinine, so much abused as in the fever of tubercu-
losis. In large doses it has a moderate antipyretic action, but it is just
in these efficient doses that it is so apt to disturb the stomach.
Antipyrin and antifebrin may be used cautiously ; but it is better,
when the fever rises above 103°, to rely upon cold sponging or the tepid
bath, gradually cooled. When softening has taken place and the fever
assumes the characteristic septic type, the problem becomes still more
difficult. As shown by Chart XIII (which is not by any means an ex-
ceptional one), the pyrexia, at this stage, lasts only for twelve or fifteen
hours. As a rule it is not more than from eight to ten hours in which
the fever is high enough to demand antipyretic treatment. Sometimes
antifebrin, given in two-grain doses every hour for three or four hours
before the rise in temperature takes place, either prevents entirely or
limits the paroxysm. If the temperature begins to rise between two and
three in the afternoon, the antifebrin may be given at eleven, twelve, one,
and, if necessary, at two. It answers better in this way than given in the
single doses. Careful sponging of the extremities for from half an hour
to an hour during the height of the fever is useful. Quinine is of little
benefit in this type of fever ; the salicylates still less.
(b) Sweating. — The atropine, in doses of gr. ji-Q—^-^-, and the aromatic
sulphuric acid in large doses are the best remedies. When there are
cough and nocturnal restlessness, an eighth of a grain of morphia may
be given with the atropine. Muscarin (tt[ v of a one per cent solution),
tincture of nux vomica (tt|, xxx), picrotoxin (gr. -g^) may be tried. The
patient should use light flannel night-dresses, as the cotton night-shirts,
when soaked with perspiration, have a very unpleasant cold, clammy
feeling.
(6') The cough is a troublesome, though necessary, feature in pulmo-
nary tuberculosis. Unless very worrying and disturbing sleep at night,
or so severe as to produce vomiting, it is not well to attempt to restrict
it. When irritative and bronchial in character, inhalations are useful,
particularly the tincture of benzoin or preparations of tar, creasote, or
turpentine. The throat should be carefully examined, as some of the
most irritable and distressing forms of cough in phthisis result from
laryngeal erosions. The distressing nocturnal cough, which begins just as
the patient gets into bed and is preparing to fall asleep, requires, as a rule,
preparations of opium. Codeia, in quarter or half grain doses, or the
syrupus codeiae ( 3 j) may be given. An excellent combination for the
nocturnal cough of phthisis is morphia (gr. -J-J), dilute hydrocyanic acii
(TTj, ij-iij), and syrup of wild cherry ( 3 j)- The spirits of chloroform,
h. p., or the mistura chloroformi, U. S. P., or Hoffman's anodyne, given
256 SPECIFIC INFECTIOUS DISEASES.
in whisky before going to sleep, are efficacious. Mild counter-irritation,
or the application of a hot poultice, will sometimes promptly relieve the
cough. In the later stages of the disease, when cavities have formed, the
accumulated secretion must be expectorated and the paroxysms of coughing
are now most exhausting. The sedatives, such as morphia and hydrocyanic
acid, should be given cautiously. The aromatic spirits of ammonia in full
doses help to allay the paroxysm. When the expectoration is profuse,
creasote internally, or inhalations of turpentine and iodine, are useful.
(d) For the diarrhcea large doses of bismuth, combined with Dover
powder, and small starch enemata, with or without opium, may be given.
The acetate of lead and opium pill often acts promptly, and the acid diar-
rhoea mixture, dilute acetic acid (tti x-xv), mor2)hia (gr, ^), and acetate of
lead (gr. j-ij), may be tried.
{e) The treatment of the haemoptysis will be considered in the section
on haemorrhage from the lungs. Dyspnoea is rarely a prominent symptom
except in the advanced stages, when it may be very troublesome and dis-
tressing. Ammonia and morphia, cautiously administered, may be used.
If the pleuritic pains are severe, the side may be strapped or painted
with tincture of iodine. The dyspeptic symptoms require careful treat-
ment, as the outlook in individual cases depends much upon the condition
of the stomach. Small doses of calomel and soda often allay the dis-
tressing nausea of the early stage.
XXVII. LEPROSY.
Definition. — A chronic infectious disease caused by the bacillus
leprce^ characterized by the presence of tubercular nodules in the skin
and mucous membranes (tubercular leprosy) or by changes in the nerves
(anaesthetic leprosy). At first these forms may be separate, but ulti-
mately both are combined, and in the characteristic tubercular form there
are disturbances of sensation.
Etiology. — The disease is very widely spread, and within the past
few years renewed attention has been directed to it, owing to a belief that
it is greatly on the increase. It is one of the oldest of known diseases.
At present it prevails widely, particularly in hot countries. In India it is
estimated that there are over 250,000 lepers. In Europe, where it pre-
vailed in the middle ages, it has become almost unknown except in
Norway and in the Orient. On this continent leprosy exists in the
Gulf States and extensively in Mexico. At Key West Berger states
that there are one hundred cases, and Blanc found forty lepers in Kew
Orleans. A few isolated cases arrive from time to time in the cities of
tlie Atlantic coast. In the Northwestern States a few cases exist among
the Norwegian and Icelandic settlers. On the Pacific coast cases are seen
not infrequently among the Chinese. An endemic focus is at Tracadie,
LEPROSY. 257
New Brunswick. A few cases are also met with in Cape Breton, N. S.
At Tracadie, which is on a bay of the Gulf of St. Lawrence, the disease is
limited to two or three counties which are settled by French Canadians.
The disease was imported from Normandy about the end of the last
century. The cases are confined in a lazaretto, to which they are sent so
soon as the disease is manifest. I made a visit to the settlement two years
ago with the medical officer, A. A. Smith, of Chatham, at which time
there were only eighteen patients in the hospital. It is interesting to
note that the disease has gradually diminished by segregation ; formerly
there were over forty under surveillance.
In the Sandwich Islands leprosy has developed to an enormous extent.
Morrow states that in 1889 there were 1,100 lepers in the settlement at
Molokai.
In the West Indies the disease has been long endemic, and Beavan
Eake, of Trinidad, has contributed some of the most interesting of recent
clinical and pathological studies.
The disease attacks all classes and persons of all ages. It is probably
communicated by contagion. Inoculation was successfully performed by
Arning in a Hawaiian convict. Graham, who some years ago carefully
investigated the Tracadie settlement, came to the conclusion that the
disease was there probably transmitted by contagion ; and A. A. Smith,
the present medical officer, tells me that he know^s of no facts which are
opposed to that view. It is, however, only contagious in the same sense
as syphilis, and just as accidental contamination with this virus is ex-
tremely rare so it is with leprosy. The closest possible contact may take
place for years, as between parent and child, without transmission, and
not one of the Sisters of Charity who have for more than forty years so
faithfully nursed the lepers at Tracadie has contracted the disease. It
is difficult to explain the rapid spread of the disease in the Sandwich
Islands on any other view than contagion, and yet it is stiange that there
is no evidence of a primary lesion or external sore comparable to that of
syphilis. Morrow states that " in the immense majority of cases the
disease is propagated by sexual congress."
The disappearance of the disease in the middle ages no doubt resulted
directly from the isolation enforced at that time. The disease has possi-
bly in some instances been transmitted by vaccination. Hereditary trans-
mission cannot be excluded, and there is no good reason why the disease
should not be communicated, as is syphilis, from parent to child.
Jonathan Hutchinson believes that the disease is always associated with
some special kind of food, particularly fish. Though he does not deny the
specific nature of the disease or the possibility of contagion, he would
make apparently the fish diet the tertium quid which renders the patient
susceptible, or, if I gather aright from his recent communication, with
which the poison may be taken. The facts which are manifest at the
Tracadie settlement are very much opposed to this view. If a fish diet
253 SPECIFIC INFECTIOUS DISEASES.
could alone in any way induce the disease, by this time leprosy would be
wide-spread in the counties along the Gulf of St. Lawrence, as fish is the
main article of diet winter and summer. There is not the slightest differ-
ence in race, the mode of life, or in the surroundings of the inhabitants
in the regions adjacent to Caraquet and Tracadie, and yet leprosy has
been for nearly a century limited to two or three counties.
The Bacillus Leprae. — Hansen, of Bergen, first discovered this organ-
ism, which has many points of resemblance to the hacillus tuberctdosis^
but can be differentiated from it. It occurs in extraordinary numbers in
the tuberculous tissue. It has been cultivated successfully (Babes), but
inoculation experiments on animals have been negative.
Morbid Anatomy. — The leprosy tubercles consist of granuloma-
tous tissue made up of cells of various sizes in a connective-tissue matrix.
The bacilli in extraordinary numbers lie partly between and partly in the
cells. The growth gradually involves the skin, producing tuberous out-
growths with intervening areas of ulceration or cicatrization, which in the
face may gradually produce the so-called fades leontina. The mucous
membranes, particularly the conjunctiva, the cornea, the larynx, may be
gradually involved. In many cases deep ulcers form which result in
extensive loss of substance or loss of fingers or toes, the so-called lepra
mutilans. In anaesthetic leprosy there is a peripheral neuritis due to the
development of the bacilli in the nerve-fibres. Indeed, this involvement
of the nerves plays a primary part in the etiology of many of the im-
portant features, particularly the trophic changes in the skin and the
disturbances of sensation.
Clinical Forms. — {a) Tubercular Leprosy.— Prior to the appear-
ance of the nodules tliere are areas of cutaneous erythema which may be
sharply defined and often hyperaesthetic. This is sometimes known as
macular leprosy. The affected spots in time become pigmented. In some
instances this superficial change continues without the development of
nodules, the areas become anaesthetic, the pigment gradually disappears,
and the skin gets perfectly white — the le2)ra alba. Among the patients
at Tracadie it was particularly interesting to see three or four in this early
stage presenting on the face and forearms a patchy erythema with slight
swelling of the skin. The diagnosis of the condition is perfectly clear,
though it may be a long time before any other than sensory changes
develop. The eyelashes and eyebrows and the hairs on the face fall out.
The mucous membranes finally become involved, particularly the inouth,
throat, and larynx ; the voice becomes harsh and finally aphonic. Death
results not infrequently from the laryngeal complications and aspiration
pneumonia. The conjunctivae are frequently attacked, and the sight is
lost by a leprous keratitis.
{b) Anaesthetic Leprosy. — Tliis remarkable form has, in characteristic
cases, no external resemblance whatever to the other variety. It usually
begins with pains in the limbs and areas of hyperaesthesia or of numbness.
GLANDERS. 259
Very early there may be trophic changes, seen in the formation of small
bulla3 (llillis). Maciila3 appear upon the trunk and extremities, and after
persisting for a variable time gradually disa2)pear, leaving areas of anai's-
thesia, but the loss of sensation may come on independently of the out-
break of maculae. The nerve-trunks, where superficial, may be felt to be
large and nodular. The trophic disturbances are usually marked. Pem-
phigus-like bulla3 develop in the affected areas, which break and leave
ulcers which may be very destructive. The fingers and toes are liable to
contractures and to necrosis, so that in chronic cases the phalanges are
lost. The course of anaesthetic leprosy is extraordinarily chronic and may
persist for years without leading to much deformity. One of the most
prominent clergymen on this continent has had anaesthetic leprosy for
more than thirty years, which until recently has not seriously interfered
with his usefulness, and not in the slightest with his career.
Diagnosis. — Even in the early stage the dusky erythematous maculae
with hyperaesthesia or areas of anaesthesia are very characteristic. In an
advanced grade neither the tubercular nor anaesthetic forms could possi-
bly be mistaken for any other affection.
Treatment. — There are no specific remedies in the disease, and gen-
eral tonics combined with local treatment meet the only available indica-
tions. The gurjun and chaulmoogra oils have been recommended, the
former in doses of from five to ten minims, the latter in two-drachm doses.
The cases should be isolated, although the risk of catching the disease by
direct contagion is extremely slight.
XXVIII. GLANDERS {Farcy).
Definition. — An infectious disease of the horse, communicated occa-
sionally to man. In the horse it is characterized by the formation of
nodules, chiefly in the nares (glanders) and beneath the skin (farcy).
Etiology. — The disease belongs to the infective granulomata. The
local manifestations in the nostrils and the skin of the horse are due to
one and the same cause. The specific germ was discovered by Loeffler
and Schiitz. It is a short, non-motile bacillus, not unlike that of tubercle.
It grows readily on the ordinary culture media. For the full recognition
of glanders in man we are indebted to the labors of Rayer, whose mono-
graph remains one of the best descriptions ever given of the disease.
Man becomes infected by contact with diseased animals, and usually by
inoculation on an abraded surface of the skin. The contagion may also
be received on the mucous membrane. In one of the Montreal cases a
gentleman was probably infected by the material expelled from the nos-
trils of his horse, whicli was not suspected to have the disease.
Morbid Anatomy. — As in the horse, the disease may be localized
in the nose (glanders), or beneath the skin (farcy). The essential lesion
260 SPECIFIC INFECTIOUS DISEASES.
is the granulomatous tumor, characterized by the presence of numerous
lymplioid and epithelioid cells, among and in which are seen the glanders
bacilli. These nodular masses tend to break down rapidly, and on the
mucous membrane form ulcers, while beneath the skin they form ab-
scesses. The glanders nodules may also occur in the internal organs.
Symptoms. — An acute and a chronic form of glanders may be recog-
nized in man, and an acute and a chronic form of farcy.
Acute Glanders. — The period of incubation is rarely more than three
or four days. There are signs of general febrile disturbance. At the
place of infection there are swelling, redness, and lymphangitis. Within
two or three days there is involvement of the mucous membrane of the
nose, the nodules break down rapidly to ulcers, and there is a muco-
purulent discharge. An eruption of papules, wdiich rapidly become pust-
ules, breaks out over the face and about the joints. It has been mistaken
for variola. This was carefully studied by Rayer and is figured in his
monograph. In a Montreal case this copious eruption led the attending
physician to suspect small-pox, and the patient was isolated. There is
great swelling of the nose. The ulceration may go on to necrosis, in
which case the discharge is very offensive. The lymph-glands of the neck
are usually much enlarged. Subacute pneumonia is very apt to develop.
This form runs its course in about eight or ten days, and is invariably
fatal.
Chronic glanders is rare and difficult to diagnose, as it is usually
mistaken for a chronic coryza. There are ulcers in the nose, and often
laryngeal symptoms. It may last for months, or even longer, and recovery
sometimes takes place. The diagnosis may be extremely difficult. In
such cases cultures should be made and portions of the pure culture inocu-
lated in the guinea-pig. The animal dies within thirty hours, and the
testicles are found to be enormously swollen and already in the condition
of abscess.
Acute farcy in man results usually from the inoculation of the virus
into the skin. There is an intense local reaction with a phlegmonous in-
flammation. The lymphatics are early affected, and along their course
there are nodular subcutaneous enlargements, the so-called farcy buds,
which may rapidly go on to suppuration. There are pains and swelling
in the joints and abscesses may form in the muscles. The symptoms are
those of an acute infection, almost like an acute septic.Tmia. The nose is
not involved and the superficial skin eruption is not common.
The disease is fatal in a large proportion of the cases, usually in from
twelve to fifteen days.
Chronic farcy is characterized by the presence of localized tumors, usu-
ally in the extremities. These tumors break down into abscesses, and
sometimes form deep ulcers, without much inflammatory reaction and
without special involvement of the lymphatics. The disease may last for
months or even years. Death may result from pyaemia, or occasionally
ACTINOMYCOSIS. 201
acute glanders develops. The celebrated French veterinarian, Bouley,
had it and recovered.
The disease is transmissible also from man to man. Washer-women
have been infected from the clothes of a patient. In the diagnosis of this
affection the occupation is very important. Nowadays, in cases of doubt,
the inoculation should be made in animals, as in this way the disease can
be readily determined.
Treatment. — If seen early the wound should be either cut out or
thoroughly destroyed by caustics, and an antiseptic dressing applied. The
farcy buds should be early opened. In the acute cases there is very little
hope. In the chronic cases recovery is possible, though often tedious.
XXIX. ACTINOMYCOSIS.
Definition. — A chronic inflammatory affection produced by the acti-
nomyces or ray-fungus.
Etiology. — The disease is wide-spread among cattle, and occurs also
in the pig. It was first described by Bollinger in the ox, in which it forms
the affection known in this country as " big-jaw." Examples of the dis-
ease were common in the cattle killed at the abattoir in Montreal. In man
the disease was first described by James Israel, and subsequently Ponfick
insisted upon the identity of the disease in man and cattle.
In this country and in England the disease is rare, and only a few
cases have been described. Although familiar with the affection in cattle
since 1878, and constantly on the lookout for the disease, no instance has
fallen under my personal observation.
The 2^arasite is a fungus belonging to the species Cladotlirix. In both
man and cattle it can be seen in the pus from the affected region as small
yellowish granules from one half to two millimetres in diameter. Micro-
scopically these bodies are seen to be made up of threads which radiate
from a centre and present bulbous, club-like terminations. Bostrom has
recently published an elaborate research on their structure and develop-
ment.
The parasite has been successfully cultivated and the disease has been
inoculated, both with the natural and artificially grown fungus.
The Mode of Infection. — The fungus has not been detected outside the
lx)dy. It seems highly probable that it is taken in with the food. The
site of infection in a majority of cases in man and animals is in the mouth
or neighboring passages. In the cow, possibly also in man, ears of barley
or rye have been carriers of the fungus.
Morbid Anatomy. — In the earliest stages of its growth the para-
site gives rise to a small granulation tumor, not unlike that produced by
the hacilluH luherculo.HiS, which contains, in addition to small round cells,
epithelioid elements and giant cells. After it reaches a certain size there
262 SPECIFIC INFECTIOUS DISEASES.
is great proliferation of tlie surroniuling connective tissue, and the growth
may, particularly in the jaw, look like, and was long mistaken for, osteo-
sarcoma. Finally suppuration occurs, which, according to Israel, may be
produced directly by the fungus itself.
Clinical Forms. — (a) Alimentary Canal. — Israel is said to have
found the fungus in the cavities of carious teeth. The jaw has been in-
volved in a number of cases in man. The patient comes under observa-
tion with swelling of one side of the face, or with a chronic enlargement
of the jaw which may simulate sarcoma. In the case described by Boda-
mer at the German Hospital, Philadelphia, the swelling involved the
right side of the face, the temporal region, and the neck ; there were nu-
merous sinuses, and the case had the appearance of chronic necrosis of the
bones.
The tongue has been involved in several cases, forming small growths,
which in one instance were primary, in the others secondary to disease of
the jaw. In the intestines the disease may occur either as a primary or
secondary affection. At the Charite in Berlin in 1884 I saw with Oscar
Israel a remarkable instance in which there w^ere actinomycotic ulcers in
the small intestines. Cases have been reported of perica3cal abscess due
to the fungus. An instance of primary actinomycosis of the large intes-
tine with metastases has also been described. The liver may be affected
primarily, as in the case reported by Sharkey and Acland.
(b) Pulmonary Actinomycosis. — In September, 1878, James Israel de-
scribed a remarkable mycotic disease of the lungs, wdiich subsequent
observation showed to be the affection described the year before by Bol-
linger in cattle. Since that date thirty-four instances have been reported
in which the lungs were affected. Hodenp3'l has analyzed these and
reports two cases from the Roosevelt Hospital.
It is a chronic infectious disorder of the lungs, characterized by cough,
fever, wasting, and a muco-purulent, sometimes fa3tid, expectoration. The
lesions are unilateral in a majority of the cases. Ilodenpyl classifies them
in three groups : (1) Lesions of chronic bronchitis ; in one case the diag-
nosis was made by the presence of the actinomyces in the sputum. (2)
Miliary actinomycosis, closely resembling miliary tubercle, but the nodules
are seen to be made up of groups of fungi, surrounded by granulation
tissue. This form of pulmonary actinomycosis is not infrequent in oxen
with advanced disease of the jaw or adjacent structures. (3) The cases
in which there is more extensive destructive disease of the lungs, broncho-
pneumonia, interstitial changes, and abscesses, the latter forming cavities
large enough to be diagnosed during life. Actinomycotic lesions of other
organs are often present in connection with the pulmonary disease : ero-
sion of the vertebrae, necrosis of the ribs and sternum, subcutaneous ab-
scesses, and occasionally metastases in all parts of the body.
Sjimptoms. — The fever is of an irregular type and depends largely on
the existence of suppuration. The cough is an important symptom, and
ACTINOMYCOSIS. 263
the diagnosis in eighteen of the cases was made during life by the discov-
ery of the actinomyces. Death results usually with septic symptoms.
Occasionally there is a condition simulating typhoid fever. The average
duration of the disease was ten months. Of the thirty-four cases all died
except two. Clinically the disease closely resembles certain forms of pul-
monary tuberculosis and of fa3tid bronchitis. It is not to be forgotten in
the examination of the sputum that, as Bizzozero mentions, certain degen-
erated epithelial cells may resemble the fungus. The radiating leptothrix
threads about the epithelium of the mouth sometimes present a striking
resemblance.
(c) Cutaneous Actinomycosis. — In several instances in connection with
chronic ulcerative disease of the skin the ray-fungus has been found. It
is a very chronic affection associated with the development of tumors
which suppurate and leave open sores which mny remain for years. It
resembles tuberculosis of the skin.
(d) Cerebral Actinomycosis. — Bollinger has reported an instance of
primary disease of the brain. The symptoms were those of tumor. A
second remarkable case has been reported by Gamgee and Delepine.
The patient was admitted to St. George's Hospital with left-sided pleural
effusion. At the post-mortem three pints of purulent fluid were found in
the left pleura ; there was an actinomycotic abscess of the liver, and in the
brain there were abscesses in the frontal, parietal, and temporo-sphenoidal
lobes which contained the mycelium, but no clubs. A third case, re-
ported by 0. B. Keller, had empye7na iiecessitatis^ which was opened
and actinomyces were found in the pus. Subsequently she had Jack-
sonian epilepsy, for which she was trephined twice and abscesses opened,
which contained actinomyces grains. Death occurred after the second
operation.
Diagnosis. — The disease is often mistaken for and is in reality a
chronic pyaemia. The only test is the presence of the actinomyces in the
pus. Metastases may occur as in pyaemia and in tumors. The tendency,
however, is rather to produce a local purulent affection which erodes the
bones and is very destructive. In cattle the disease may cause metastases
without any suppuration ; thus in a Montreal case the jaw and tongue
were the seat of the most extensive disease with very slight suppuration,
while the lungs presented numbers of secondary growths containing the
fungus.
Treatment. — This is largely surgical and is practically that of py-
aemia. Incision of the abscess, removal of the dead bone, and thorough
irrigation are appropriate measures.
18
264 SPECIFIC INFECTIOUS DISEASES.
XXX. INFECTIOUS DISEASES OF DOUBTFUL NATURE.
(1) FEBRICULA— EPHEMERAL FEVER.
Definition. — Fever of slight duration, probably depending upon a
variety of causes.
A febrile paroxysm lasting for twenty-four hours and disappearing com-
pletely is spoken of as ephemeral fever. If it persists for three, four, or
more days without local affection it is referred to as febricula.
The cases may be divided into several groups :
(a) Those which represent mild or abortive types of the infectious
diseases. It is not very infrequent, during an epidemic of typhoid, scarlet
fever, or measles, to see cases with some of the prodromal symptoms and
slight fever which persist for two or three days without any distinctive
features. I have already spoken of these in connection with the abortive
type of typhoid fever. Possibly, as Kahler suggests, some of the cases of
transient fever are due to the rheumatic poison.
(b) In a larger and perhaps more important group of cases the symp-
toms develop with dyspepsia. In children indigestion and gastro-intes-
tinal catarrh are often accompanied by fever. Possibly some instances
of longer duration may be due to the absorption of certain toxic sub-
stances. Slight fever has been known to follow the eating of decompos-
ing substances or the drinking of stale beer; but the gastric juice has
remarkable antiseptic properties, and the frequency with which persons
take from choice articles which are " high," shows that poisoning is not
likely to occur unless there is existing gastro-intestinal disturbance.
(c) Cases which follow exposure to foul odors or sewer-gas. That a
febrile paroxysm may follow a prolonged exposure to noxious odors has
long been recognized. The cases which have been described under this
heading are of two kinds : an acute severe form with nausea, vomiting,
colic, and fever, followed perhaps by a condition of collapse or coma ;
secondly, a form of low fever with or without chills. A good deal of
doubt still exists in the minds of the profession about these cases of so-
called sewer-gas poisoning. It is a notorious fact that workers in sewers
are remarkably free from disease, and in many of the cases which have
been reported the illness may have been only a coincidence. There are
instances in which persons have been taken ill with vomiting and slight
fever after exposure to the odor of a very offensive post-mortem. Whether
true or not, the idea is firmly implanted in the minds of the laity that very
powerful odors from decomposing matters may produce sickness.
(d) Many cases doubtless depend upon slight unrecognized lesions,
such as tonsillitis or occasionally an abortive or larval pneumonia. Chil-
dren are much more frequently affected than adults.
The symptoms set in, as a rule, abruptly, though in some instances
there may have been preliminary inalaise and indisposition. Headache,
INFECTIOUS DISEASES OF DOUBTFUL CUARACTKIL 265
loss of appetite, and furred tongue are present. The urine is scanty and
high-colored, the fever ranges from 101° to 103°, sometimes in children it
rises higher. The cheeks may be flushed and the patient has the outward
manifestations of fever. In children there may be bronchial catarrh with
slight cough. Herpes on the lips is a common symptom. Occasionally
in children the cerebral symptoms are marked at the outset, and there
may be irritation, restlessness, and nocturnal delirium. The fever termi-
nates abruptly by crisis from the second to the fourth day ; in some in-
stances it may continue for a week.
The diagnosis generally rests upon the absence of local manifestations,
particularly the characteristic skin rashes of the eruptive fevers, and most
important of all the rapid disappearance of the pyrexia. The cases most
readily recognized are those with acute gastro-intestinal disturbance.
The treatment is that of mild pyrexia — rest in bed, a laxative, and a
fever mixture containing nitrate of potash and sweet spirits of nitre.
(2) WEIL'S DISEASE.
Acute Febrile Icterus. — In 1886 Weil described an acute infectious
disease, characterized by fever and jaundice. Much discussion has taken
place concerning the true nature of this affection, but it has not been
definitely determined whether it is a specific disease or only a jaundice
which may be due to various causes. The majority of the cases have oc-
curred during the summer months. The cases have occurred in groups in
different cities. A few cases have been reported in this country (Lan-
phear). Males are most frequently affected. Many of the cases have been
in butchers. The age of the patients has been from twenty-five to forty.
The disease sets in abruptly, usually without prodromata and often
with a chill. There are headache, pains in the back, and sometimes in-
tense pains in the legs and muscles. The fever is characterized by marked
remissions. Jaundice appears early. The liver and spleen are usually
swollen ; the former may be tender. The jaundice may be light, but in
many of the cases described it has been of the obstructive form, and the
stools have been clay-colored. Gastro-intestinal symptoms are rarely pres-
ent. The fever lasts from ten to fourteen days ; sometimes there are slight
recurrences, but a definite relapse is rare.
Albumen is usually present in the urine ; haematuria has occurred in
some cases.
Cerebral symptoms, delirium and coma, have been met.
In the few post-mortems which have been made nothing distinctive
has been found. Its occurrence as an independent malady, apart from
other infectious processes, has scarcely yet been definitely established.
266 SPECIFIC INFECTIOUS DISEASES.
(3) MILK-SICKNESS.
This remarkable disease prevails in certain districts of the United
States, west of the Alleghany Mountains, and is connected with the affec-
tion in cattle known as the trembles. It prevailed extensively in the early
settlements in certain of the Western States and proved very fatal. The
general opinion is that it is communicated to man only by eating the flesh
or drinking the milk of diseased animals. The butter and cheese are also
poisonous. In animals, cattle and the young of horses and sheep are most
susceptible. It is stated that cows giving milk do not themselves show
marked symptoms unless driven rapidly, and, according to Graff, the secre-
tion may be infective when the disease is latent. When a cow is very ill,
food is refused, the eyes are injected, the animal staggers, the entire mus-
cular system trembles, and death occurs in convulsions, sometimes with
great suddenness. Nothing definite is known as to the cause of the dis-
ease. It is most frequent in new settlements.
In man the symptoms are those of a more or less acute intoxication.
After a few days of uneasiness and distress the patient is seized with pains
in the stomach, nausea and vomiting, fever and intense thirst. There is
usually obstinate constipation. The tongue is swollen and tremulous, the
breath is extremely foul and, according to Graff, is as characteristic of the
disease as the odor is of small-pox. Cerebral symptoms — restlessness,
irritability, coma, and convulsions — are sometimes marked, and there may
gradually be produced a typhoid state in which the patient dies.
The duration of the disease is variable. In the most acute forms death
occurs within two or three days. It may last for ten days, or even for
three or four weeks. Graff states that insanity occurred in one case. The
poisonous nature of the flesh and of the milk has been demonstrated ex-
perimentally. An ounce of butter or cheese, or four ounces of the beef,
raw or boiled, three times a day will kill a dog within six days. No defi-
nite pathological lesions are known. Fortunately, the disease has become
rare, and the observation of Drake, Yandell, and others, that the disease
gradually disappears with the clearing of the forests and improved tillage,
has been amply substantiated. It still prevails in parts of North Carolina.
(4) MALTA FEVER.
This disease, also known as Mediterranean fever, Neapolitan fever, and
rock fever, has been studied particularly by the naval and military medi-
cal officers who liave been stationed on the island of Malta. It prevails
also in Naples and other districts of the Mediterranean. AVhile endemic
in tlie islaiul of ^lalta, the disease in some years reaches epidemic propor-
tions. Young persons are, as a rule, affected. The incubation may be
from six to ten days.
The symptoms are thus briefly and clearly described in an editorial in
INFECTIOUS DISEASES OP DOUBTFUL CIIARACTEU. 267
the British Medical Journal : " The disease declares itself gradually, with
headache, sleeplessness, loss of api)etite, and thirst, often without shiver-
ing or diarrhcjua, and without spots. Symptoms of this kind, with more
or less severity, last for three or four weeks; apparent but deceptive con-
valescence then usually sets in, to be followed in a few days by a relapse,
with rigors, intense headache and fever, with, frequently, diarrhoea. In
this state the patient may continue for five or six weeks, with more or less
delirium. Improvement again sets in, to be followed, it may be, by an-
other relapse in about ten days or a fortnight, with shivering, headache,
sleeplessness, great debility, with night-sweats, pains in the hips, knees,
ankles, and elbows, and often in one or both testicles. Again, the patient
enters on a state of convalescence, which may last for a month or six
weeks. The old symptoms may again appear, with extreme debility, a
thickly coated tongue, with thirst, a temperature ranging from 105° Fahr.
in the evening to nearly normal in the morning, with night-sweats bring-
ing no relief to the general distress. The rheumatic symptoms are the
most constant and the most distressing ; all the joints, large and small,
may suffer. Dr. Veale described cases in which the intervertebral joints,
especially those of the lumbar region and the sacro-iliac synchondroses,
were so severely affected that the patient " dreads every movement " ; he
will lie for days in one position, risking the formation of bed-sores, and
resisting the desire to evacuate his bowels rather than encounter the suf-
fering that a movement will entail. Oftentimes the tendo Achillis and
the fibrous structures around the ankle-joint are involved ; but perhaps
the lumbar aponeuroses and the sheaths of the nerves issuing from the
sacral plexus are still more commonly affected."*
The nature of the disease is still under discussion. McLean, of the
Army Medical School, in 1879, suggested that it was a typho-malarial
fever, and Veale called it fehris complicata. Others liave supposed that
it is an anomalous form of malaria, but it does not behave like any ordi-
nary form of paludal fever and resists quinine. This is a question which
could be determined positively by the blood examination. According to
Bruce, no characteristic typhoid lesions are found in fatal cases. This
author has described the presence of a micrococcus in the spleen. The
Italian observers have noted enlargement of the mesenteric glands, and
Cantani regards it as an adeno-typhoid. The identity of Malta and the
so-called rock fever of Gibraltar is, however, by no means certain. In the
number of the Journal referred to. Surgeon Perry states that of about a
hundred autopsies during four years in Gibraltar, in cases of the so-called
rock fever, in not one were the typical lesions of typhoid absent. On the
other hand, it is held to be a fever due to chronic poisoning with faecal
emanations.
Fortunately, the mortality is not great. With reference to the treat-
* British Medical Journal, vol. i, 1889.
268 SPECIFIC INFECTIOUS DISEASES.
ment Bruce concludes that it should be directed principally to keeping
the patient's strength up by fluid, easily digested food, by stimulants when
required and by attention to ordinary hygienic principles. The removal
of the patient from the infected area does not cut short the fever.
(5) MOUNTAIN FEVER.
Residence for a time at a high altitude is in some instances followed by
a group of symptoms to which the term mountain sickness or mountain
fever has been given. Several distinct diseases have undoubtedly been
described. It is by no means certain that there is a special affection to
which the term may be applied. An important group, the mountain
ancemia^ is associated with the anchylostoma^ which has not yet been met
with in this country. A second group of cases belongs unquestionably to
typhoid fever, and undoubted instances of this disease occurring in mount-
ainous regions in the West are referred to as mountain fever.
In the very full and clear report which Hoff * gives of five cases, the
clinical picture is that of typhoid fever, and one of the patients died of
perforation of the ileum with well-defined typhoid lesion. Even from the
clinical reports, unless biased, by notions of a rigidly characteristic picture
of the disease, one might have said that all of Surgeon Hoff's cases were
typhoid fever, and the post-mortem record leaves no question as to the
nature of the malady. Woodward, commenting upon this communication,
states that there is in the United States Army Medical Museum a second
specimen from the case of so-called mountain fever contributed by Sur-
geon Girard.
Smart, who reviewed the entire question a few years ago, regarded the
disease as a typho- malarial fever; but there is nothing in his account
opposed to the opinion that it is a typhoid fever.
There is a third group to which, perhaps, alone the term mountain
sickness should be applied — cases which present respiratory and cardiac
symptoms, due to a high altitude. The pulse is rapid, there are giddiness,
headache, sometimes nausea and vomiting, sensations of great prostration,
and considerable respiratory distress. The original cases described by
General Fremont were of this nature.
(6) MILIARY FEVER— SWEATING SICKNESS.
The disease is characterized by fever, profuse sweats, and an eruption
of miliary vesicles. The disease prevailed and was very fatal in England
in the fifteenth and sixteenth centuries, but of late years it has been con-
fined entirely to certain districts in France (Picardy) and Italy. An
epidemic of some extent occurred in France in 1887. Ilirscli gives a
* American Journal of the Medical Sciences, January, 1880.
INFECTIOUS DISEASES OP DOUBTFUL CHARACTER. 209
chronological account of 194 epidemics between 1718 and 1879, many
of which were limited to a single village or to a few localities. Occasion-
ally the disease has become widely spread. Slight epidemics have oc-
curred in Germany and Switzerland. They are usually of short duration,
lasting only for three or four weeks — sometimes not more than seven or
eight days. As in influenza, a very large number of persons are attacked in
rapid succession. In the mild cases there is only slight fever, with loss of
appetite, an erythematous eruption, profuse perspiration, and an outbreak
of miliary vesicles. The severe cases present the symptoms of intense
infection — delirium, high fever, profound prostration, and haemorrhage.
The death-rate at the outset of the disease is usually high, and, as is so
graphically described in the account of some of the epidemics of the mid-
dle ages, death may follow in a few hours.
SECTION II.
CONSTITUTIOIs^AL DISEASES.
I. RHEUMATIC FEVER.
Definition. — An acute, non-contagious, febrile affection, depending
probably upon an unknown infective agent, and characterized by multiple
arthritis and a special tendency to involve the heart.
Etiology. — Acute rheumatism prevails in temperate and in humid
climates. It is rare in the tropics. Statistics on the point are not availa-
ble, but, judging from my own observations, I think that, in hospital
practice at least, cases are much more frequent in England than in Amer-
ica. It prevails most extensively during the spring months. In Bell's
statistics, of 456 cases treated, at the Montreal General Hospital during
ten years, the largest number of cases were admitted in February, March,
and April. The same proportion seems true in Europe and in the cities
of the Atlantic coast.
Age. — Young adults are most frequently affected, but the disease is by
no means uncommon in children between the ages of ten and fifteen years.
Sucklings are rarely affected, and probably many of the cases which have
been described belong to a totally different affection, the arthritis of in-
fants. In exceptional cases, however, true rheumatism does occur. The
following age table is based upon 456 cases admitted to the Montreal Gen-
eral Hospital : Under 15 years, 4*38 per cent ; from 15 to 25 years, 48*68
per cent ; from 25 to 35 years, 25*87 per cent ; from 35 to 45 years, 13*6
per cent; above 45 years, 7*4 per cent. Of the 655 cases analyzed by
Whipham for the Collective Investigation Committee of the British Medi-
cal Association, only 32 cases occurred under the tenth year and 80 per
cent between the twentieth and fortieth year. These figures scarcely give
the ratio of cases in children.
Sex. — If all ages are taken, males are affected oftener than females.
In the Collective Investigation Report there were 375 males and 279
females. Up to the age of twenty, however, females predominate. Be-
tween the ages of ton and fifteen girls are more prone to the disease.
Occupations which necessitate exposure to cold and to great changes
RHEUMATIC FEVER. 271
in temperature predispose strongly to rheumatism. "We meet the disease
oftenest in drivers, servants, bakers, sailors, and laborers. Heredity seems
in some cases to have a special inliuence, and the disease is more common
in certain families. Of all etiological factors, cold is believed to be the
most potent. Many cases follow a sudden wetting or chilling of the skin.
The essential cause of rheumatism is still unknown. There are three
chief theories :
(a) MetahoUc : that it depends upon a morbid material produced
within the system in defective processes of assimilation. It has been sug-
gested that this material is lactic acid (Prout) or certain combinations
with lactic acid (Latham). Our knowledge of the chemical relations of
the various products produced in the regressive nutritive changes is too
limited to base much reliance upon these views. Richardson claims to
have produced rheumatism by injecting lactic acid and by its internal ad-
ministration.
{b) The nervous theory advanced by J. K. Mitchell has many advo-
cates. According to this view, either the nerve-centres are primarily
affected by cold and the local lesions are really trophic in character, or
the primary nervous disturbance leads to errors in metabolism and the
accumulation of lactic acid in the system. The advocates of this view
regard as analogous the arthropathies of myelitis, locomotor ataxia, and
chorea.
(6-) Germ theory : that the arthritis is due to a specific microbe. In
favor of this view may be mentioned the close analogy which exists be-
tween rheumatism and certain of the infectious diseases. The analogy is
marked with gonorrhoea, scarlet fever, and septic processes, which are fre-
quently associated with arthritis and endocarditis. The investigations
hitherto made have not, however, shown the constancy of any micro-
organism in the disease. Mantle and others have described micrococci in
the blood, and several organisms have been found in the secondary inflam-
mations of the disease, but none of them can be said to be specific or
peculiar.
Morbid Anatomy. — There are no changes characteristic of the
disease. The affected joints show hyperajmia and swelling of the synovial
membranes and of the ligamentous tissues. There may be slight erosion
of the cartilage. The fluid in the joint is turbid, albuminous in charac-
ter, and contains leucocytes and a few fibrin flakes. Pus is very rare in
uncomplicated cases. Rheumatism rarely proves fatal, except when there
are serious complications, such as pericarditis, endocarditis, myocarditis,
pleurisy, or pneumonia. The conditions found have nothing peculiar,
nothing to distinguish them from other forms of inflammation. In death
from hyperpyrexia no special changes occur. The blood usually contains
an excessive amount of fibrin. In the secondary rheumatic inflammations,
as pleurisy and pericarditis, various pus organisms have been found, possi-
bly the result of a mixed infection.
272 CONSTITUTIONAL DISEASES.
Symptoms. — As a rule, the disease sets in abruptly, but it may be
preceded by irregular pains in the joints, slight malaise, sore throat, and
particularly by tonsillitis. A definite rigor is uncommon ; more often
there is slight chilliness. The fever rises quickly, and with it one or more
of the joints become painful. Within twenty-four hours from the onset,
the disease is fully developed. The temperature range is from 102° to
104°. The pulse is frequent, soft, and usually above 100. The tongue is
moist, and rapidly becomes covered with a white fur. There are the ordi-
nary symptoms associated with an acute fever, such as loss of appetite,
thirst, constipation, and a scanty, highly acid, highly colored urine. In a
majority of the cases there are profuse, very acid sweats, of a peculiar sour
odor. Sudaminal and miliary vesicles are abundant. The mind is clear,
except in the cases with hyperpyrexia. The affected joints are painful to
move, and soon become swollen and hot, and present a reddish flush.
The knees, ankles, elbows, and wrists are the joints usually attacked, not
together, but successively. For example, if the knee is first affected, the
redness may disappear from it as the wrists become painful and hot.
The disease is seldom limited to a single articulation. The amount of
swelling is variable. Extensive effusion into a joint is rare, and much of
the enlargement is due to the infiltration of the periarticular tissues with
serum. The swelling may be limited to the joint proper, but in the wrists
and ankles it sometimes involves the sheaths of the tendons and produces
great enlargement of the hands and feet. Corresponding joints are often
affected. In attacks of great severity every one of the larger joints may
be involved. The vertebral, sterno-clavicular, and phalangeal articula-
tions are less often inflamed in acute than in gonorrhoeal rheumatism.
Perhaps no disease is more painful than acute polyarthritis. The in-
ability to change the posture without agonizing pain, the drenching
sweats, the prostration and utter helplessness, combine to make it one of
the most distressing of febrile affections. A special feature of the disease
is the tendency of the inflammation to subside in one joint while develop-
ing with great intensity in another.
The temperature range in an ordinary attack is between 102° and
104°. It is peculiarly irregular, with marked remissions and exacerba-
tions, depending very much upon the intensity and extent of the articular
inflammation. Defervescence is usually gradual. The profuse sweats
materially influence the temperature curve. If a two-hourly chart is made
and observations upon the sweats are noted, the remissions will usually be
found coincident with the sweats. The perspiration is sour-smelling and
acid at first; but, when persistent, becomes neutral or even alkaline.
The blood is profoundly and rapidly altered in acute rheumatism.
There is, indeed, no acute febrile disease in which the ana?mia develops
with greater rapidity.
With the high fever a murmur may often be heard at the apex re-
gion. Endocarditis is also a common cause of an apex bruit. The heart
RHEUMATIC FEVER. 273
should be carefully examined at the first visit and subsequently each
day.
The urine is, as a rule, reduced in amount, of high density and high col-
or. It is very acid, and, on cooling, deposits urates. The chlorides may be
greatly diminished or even absent. Febrile albuminuria is not uncommon.
The saliva may become acid in reaction and is said to contain an
excess of sulphocyanides.
Subacute Rheumatism.
This represents a milder form of the disease, in which all the symp-
toms are less pronounced. The fever rarely rises above 101° ; fewer joints
are involved ; and the arthritis is less intense. The cases may drag on for
weeks or months, and the disease may finally become chronic. It should
not be forgotten that in children this mild or subacute form may be asso-
ciated with endocarditis or pericarditis.
Complications. — These are important and serious.
(1) Hyperpyrexia. — The temperature may rise rapidly a few days after
the onset, and be associated with delirium ; but not necessarily, for the
temperature may rise to 108° or, as in one of Da Costa's cases, 110°, without
cerebral symptoms. The delirium may precede or follow the onset of the
hyperpyrexia. As a rule, with the high fever, the pulse is feeble and fre-
quent, the prostration is extreme, and finally stupor supervenes.
(2) Cardiac Affections. — (a) Endocarditis^ the most frequent and seri-
ous complication, occurs in a considerable percentage of all cases. The
statistics upon this point are not of much value, as the diagnosis has been
based, as a rule, upon the development of a systolic murmur at apex or
base. This is quite untrustworthy ; since it may depend upon causes
other than endocarditis. The mitral segments are most frequently in-
volved and the affection is usually of the simple, verrucose variety. Ulcer-
ative endocarditis in the course of acute rheumatism is very rare. Of 209
cases of this disease which I analyzed, in only 24 did the symptoms of a
severe endocarditis arise during the progress of acute or subacute rheuma-
tism. This complication, in itself, is rarely dangerous. It produces few
symptoms and is usually overlooked. Unhappily, though the valve at the
time may not be seriously damaged, the inflammation starts changes which
lead to sclerosis and retraction of the segments, and so to chronic valvular
disease.
(b) Pericarditis may occur independently of or together with endo-
carditis. It may be simple fibrinous, sero-fibrinous, or in children puru-
lent. Clinically we meet it more frequently in connection with rheuma-
tism than all other affections combined. The physical signs are very
characteristic. The condition will be fully described under its appropriate
section. A peculiar form of delirium may develop during the progress of
rheumatic pericarditis.
274 CONSTITUTIONAL DISEASES.
(r) Myocarditis is most frequent in connection with endo-pericardial
changes. The anatomical condition is a granular or fatty degeneration of
the heart-muscle, which leads to weakening of the walls and to dilata-
tion. It is not, I think, nearly so common as the other cardiac affections.
S. West has reported instances of acute dilatation of the heart in rheu-
matic fever, in one of which marked fatty changes were found in the
heart-fibres.
(3) Pulmonary Affections. — Pneumonia and pleurisy are not uncom-
mon, and frequently accompany the cases of endo-pericarditis. According
to Howard's analysis of a large number of cases, there were pulmonary
complications in only 10*5 per cent of cases of rheumatic endocarditis ; in
58 per cent of cases of pericarditis ; and in 71 per cent of cases of endo-
pericarditis. Congestion of the lung is occasionally found, and in several
cases has proved rapidly fatal.
(4) Cerebral Complications. — These are due, m part, to the h3^per-
pyrexia and in part to the special action upon the brain of the toxic agent
of the disease. They may be grouped as follows : {a) Delirium. This is
usually associated with the hyperpyrexia, but may be independent of it.
It may be active and noisy in character; more rarely a low muttering
delirium, passing into stupor and coma. Special mention must be made
of the delirium which occurs in connection with rheumatic pericarditis.
Delirium, too, may be excited by the salicylate of soda, either shortly after
its administration, or more commonly a week or ten days later, {h) Coma.,
which is more serious, may develop without preliminary delirium or con-
vulsions, and may prove rapidly fatal. Certain of these cases are asso-
ciated with hyperpyrexia ; but South ey has reported the case of a girl who,
without previous delirium or high fever, became comatose, and died in less
than an hour. A certain number of such cases, as those reported by Da
Costa, have been associated with marked renal changes and were evidently
urgemic. The coma may develop during the attack, or after convalescence
has set in. (c) Convulsions are less common, though they may precede
the coma. Of 127 observations cited by Besnier, there were 37 of delirium,
only 7 of convulsions, 17 of coma and convulsions, 54 of delirium, coma,
and convulsions, and 3 of other varieties (Howard), (d) Chorea, The
relations of this disease and rheumatism will be subsequently discussed.
It is sufficient here to say that in only 88 out of 554 cases which I have
analyzed from the Infirmary for Diseases of the Nervous System, Phila-
delphia, were chorea and rheumatism associated. It is most apt to develop
in the slighter attacks in childhood, (e) Meningitis is extremely rare,
though undoubtedly it does occur. It must not be forgotten that in
ulcerative endocarditis, which is occasionally associated with acute rheu-
matism, meningitis is frequent.
(5) Cutaneous Affections. — Sweat-vesicles have already been mentioned
as extremely common. A red miliary rash may also develop. Scarlatini-
form eruptions are occasionally seen. Purpura, with or without urticaria.
lUlEUMATIC FEVER. 275
may occur, and various forms of erythema. It is doubtful whether the
cases of extensive ])ur])ura witli urticaria and arthritis — peliosis rlieumatica
— belong truly to acute rheumatism.
(C) Rheumatic Nodules. — These curious structures, in the form of small
subcutaneous nodules attached to the tendons and fasciae, have been known
for some years ; but special attention has been paid to them of late, since
their careful study by Barlow and Warner. They vary in size from a
small shot to a large pea, and are most numerous on the fingers, hands,
and wrists. They also occur about the elbows, knees, the spines of the
vertebrae, and the scapulae. They are not often tender. They do not
necessarily come on during the fever, but may be found on its decline, or
even independently altogether of an acute attack. They may develop
with great rapidity and usually last for weeks or months. They are more
common in children than in adults, and their presence may be regarded
as a positive indication of rheumatism. They have been noted particularly
in association with severe and chronic rheumatic endocarditis. They may
occur in large numbers in adults, as in a case reported from my clinic in
Philadelphia, by J. K. Mitchell. Histologically they are made up of round
and spindle-shaped cells.
The course of acute rheumatism is extremely variable. It is, as Austin
Flint first showed, a self -limited disease, and it is not probable that medi-
cines have any special influence upon its duration or course. Gull and
Sutton who likewise studied a series of sixty-two cases without special
treatment arrived at the same conclusion.
Diagnosis. — Practically, the recognition of acute rheumatism is very
easy ; but there are several affections which, in some particulars, closely
resemble it.
(1) Multiple Secondary Arthritis. — Under this term may be embraced
the various forms of arthritis which come on or follow in the course
of the infective diseases, such as gonorrhoea, scarlet fever, dysentery, and
cerebro-spinal meningitis. Of these the gonorrha3al form will receive
special consideration and is the type of the entire group.
(2) Septic Arthritis, which develops in the course of pyaemia from
any cause, and particularly in puerperal fever. No hard and fast line
can be drawn between these and the cases in the first group ; but the
inflammation rapidly passes on to suppuration and there is more or less
destruction of the joints. The conditions under which the arthritis de-
velops give a clew at once to the nature of the case. Under this section
may also be mentioned :
(a) Acute necrosis or acute osteo-myelitis, occurring in the lower end
of the femur, or in the tibia, and which may be mistaken for acute rheu-
matism. Sometimes, too, it is multiple. The greater intensity of the local
symptoms, the involvement of the epiphyses rather than the joints, and
the more serious constitutional disturbances are points to be considered.
The condition is unfortunately often mistaken for acute arthritis, and, as
276 CONSTITUTIONAL DISEASES.
tlio treatment is essentially surgical, the error is one which may cost the
life of the patient.
(b) The acute arthritis of infants must be distinguished from rheu-
matism. It is a disease which is usually confined to one joint (the hip or
knee), the effusion in which rapidly becomes purulent. The affection is
most common in sucklings and is undoubtedly pyaemic in character.* It
may also develop in the gonorrhoeal ophthalmia or vaginitis of the new-
born, as pointed out by Clement Lucas.
(3) It is only in rare instances that gout and acute rheumatism are
confounded. The localization in a single, usually a small, joint, the age,
the history, the mode of onset — are features which enable us to recognize
the cases readily.
Treatment. — The bed should have a smooth, soft, yet elastic mattress.
The patient should wear a flannel night-gown, which may be opened all the
way down the front and slit along the outer margin of the sleeves. Three
or four of these should be made, so as to facilitate the frequent changes
required after the sweats. He may wear also a light flannel cape about the
shoulders. He should sleep in blankets, not in sheets, so as to reduce the
liability to catch cold and obviate the unpleasant clamminess consequent
upon heavy sweating. Chambers insisted that the liability to endocar-
ditis and pericarditis was much reduced when the patients were in blankets.
Milk is the most suitable diet. It may be diluted with alkaline min-
eral waters. Lemonade and oatmeal or barley water should be freely
given. The thirst is usually great and may be fully satisfied. There is
no objection to broths and soups if the milk is not well borne. The food
should be given at short and stated intervals. As convalescence is estab-
lished a fuller diet may be allowed, but meat should be used sparingly.
The local treatment is of the greatest importance. It often suffices to
wrap the affected joints in cotton. If the pain is severe, hot cloths may
be applied, saturated with Fuller's lotion (carbonate of soda, G drachms ;
laudanum, 1 oz. ; glycerine, 2 oz. ; and water, 9 oz.). Tincture of aconite
or chloral may be employed in an alkaline solution. Chloroform liniment
is also a good application. Fixation of the joints is of great Service in
allaying the pairu I have seen, in a German hospital, the joints enclosed
in plaster of Paris, apparently with great relief. Splints, padded and
bandaged with moderate firmness, Avill often be found to relieve pain.
Friction is rarely well borne in an acutely inflamed joint. Cold com-
presses are much used in Germany. The application of blisters above
and below the joint, often relieves the pain. This method, which was
used so much a few years ago, is not to be compared with the light appli-
cation of the Paquelin thermo-cautery.
Medicines have little or no control over the duration or course of the
* Townsend, Acute Arthritis of Infants, American Journal of the Medical Sciences,
January, 1890.
RHEUMATIC FEVER. 277
disease, which, like otlier self-limited affections, practically takes its own
time to disappear. Salicyl compounds, which were regarded so long as
specific in the disease, are now known to act chiefly by relieving pain.
R. P. Howard's elaborate analysis shows that they do not influence the
duration of the disease. Nor do they prevent the occurrence of cardiac
complications, while under their use relapses are considerably more fre-
quent than in any other method of treatment. In acute cases with severe
pain the salicyl compounds give prompt relief and rarely disappoint us in
their action. Sodium salicylate, in fifteen-grain doses for eight or ten
doses, may be given. The bicarbonate of potassium in twenty-grain doses
may be used with it. Many prefer salicin (gr. 20) in wafers ; others the
salicylic acid (gr. 20) or salol. I have for the past five or six years used
the oil of wintergreen, recommended by Kinnicutt, and have found it quite
as efficacious. Twenty minims may be given every two hours in milk.
The salicyl compounds are best given in full doses at the outset of the
disease, to relieve the pain. Then the dose should be reduced in fre-
quency, or, if the symptoms have abated, stopped altogether, as relapses
are certainly more frequent under their use.
Alkalies may be combined with the salicylates, or may be used alone.
The potassium bicarbonate in half-drachm doses may be given every three
or four hours until the urine is rendered alkaline. Fuller, who so warmly
supported this method of treatment, was in the habit of ordering a drachm
and a half of the sodium bicarbonate with half a drachm of potassium
acetate in three ounces of water, rendered effervescent at the time of ad-
ministration by half a drachm of citric acid or an ounce of lemon- juice.
This is given every three or four hours, and usually by the end of twenty-
four hours the urine is alkaline in reaction. The alkali is then reduced,
and the amount subsequently regulated by the degree of acidity of the
urine, only enough being given to keep the secretion alkaline. Opinion
is almost unanimous that, under the alkaline treatment, cardiac complica-
tions are less common. The combination of the salicylates with the alkali
is probably the most satisfactory. Care must be taken to watch the heart
during the administration of these remedies. In the only fatal case of
rheumatism which has come in my experience the patient had, owing to
an error, taken the full first day's dose of Fuller's alkaline treatment for
five successive days, instead of having the salt gradually reduced. She
died suddenly on the fifth day after sitting up in bed. Salicylates also, if
given largely, are very depressing to the circulation.
To allay the pain opium may be given in the form of Dover's powder,
or morphia hypodermically. Antipyrin, antifebrin, and phenacetin are
useful sometimes for the purpose. During convalescence iron is indicated
in full doses, and quinine is a useful tonic. Of the complications, hyper-
pyrexia should be treated by the cold bath or the cold-pack. The treat-
ment of endocarditis and pericarditis and the pulmonary complications
will be considered under their respective sections.
278 COXSTITUTIOXAL DISEASES.
II. CHRONIC RHEUMATISM.
Etiology. — This affection may follow an acute or subacute attack, but
more commonly comes on insidiously in persons who have passed the
middle period of life. In my experience it is extremely rare as a sequence
of acute rheumatism. It is most common among the poor, particularly
washer-women, day laborers, and those whose occupation exposes them to
cold and damp.
Morbid Anatomy. — The synovial membranes are injected, but there
is usually not much effusion. The capsule and ligaments of the joints are
thickened, and the sheaths of the tendons in the neighborhood undergo
similar alterations, so that the free play of the joint is greatly impaired.
In long-standing cases the cartilages also undergo changes, and may show
erosions. Even in cases wath the severest symptoms, the joint may be
very slightly altered in appearance. Important changes take place in the
muscles and nerves adjacent to chronically inflamed joints, particularly
in the mono-articular lesions of the shoulder or hip. Muscular atrophy
supervenes partly from disuse, partly through nervous influences, either
centric or reflex (Vulpian), or as a result of peripheral neuritis. In some
cases when the joint is much distended the wasting may be due to press-
ure, either on the muscles themselves or on the vessels supplying them.
Symptoms. — Stiffness and pain are the chief features of chronic
rheumatism. The latter is very liable to exacerbations, especially dur-
ing changes in the weather. The joints may be tender to the touch and a
little swollen, but seldom reddened. As a rule, many joints are affected ;
but there are instances in w^hich the disease is confined to one shoulder,
knee, or hip. The stiffness and pain are more marked after rest, and as the
day advances the joints may, with exertion, become much more supple.
The general health may not be seriously impaired. The disease is not
immediately dangerous. Anchylosis may occur, and ultimately the joints
may become very distorted. In many instances, particularly those in
which the pain is severe, the general health may be seriously involved
and the subjects become anaemic and very apt to suffer with neuralgia and
dyspepsia. Valvular lesions, due to slow sclerotic changes, are not un-
common. They are associated with, not dependent upon, the articular
disease.
The prof/nosis is not favorable, as a majority of the cases resist all
methods of treatment. It is, however, a disease which persists indefin-
itely, and does not necessarily shorten life.
Treatm.ent. — Internal remedies are of little service. It is important
to maintain tlie digestive functions and to keep the general health at a
high standard. Iodide of potassium, sarsaparilla, and guaiacum are some-
times beneficial. The salicylates are useless.
Local treatment is very beneficial. " Firing " with the Paquelin
cautery relieves the pain, and it is perhaps the best form of counter-
PSKUI)0-R11J^:UMAT1C AFB^ECTIONS. 279
irritation. Massage, with passive motion, helps to reduce swelling, and
prevents anchylosis. It is particularly useful in cases which are asso-
ciated with atrophy of the muscles. Electricity is not of much benefit.
Climatic treatment is very advantageous. Many cases are greatly helped
by prolonged residence in southern Europe or soutiiern California. Kich
patients should always winter in the South, and in this way avoid the
cold, damp weather.
Hydrotherapeutic measures are specially beneficial in chronic rheu-
matism. Great relief is afforded by wrapping the affected joints in cold
cloths, covered with a thin layer of blanket, and protected with oiled silk.
The Turkish bath is useful, but the full benefit of this treatment is rarely
seen except at bathing establishments. The hot alkaline waters are par-
ticularly useful, and a residence at the Hot Springs of Virginia or Ar-
kansas, or at Banff, in the Rocky Mountains, on the Canadian Pacific Rail-
way, will sometimes cure even obstinate cases.
III. PSEUDO-RHEUMATIC AFFECTIONS.
These are numerous, and occur as complications or sequelae of many
infectious diseases with which they have been considered. The one which
is of most importance, and which, though a surgical affection, is usually
treated of in works on medicine, is —
GonorrhoBal Rheumatism, — Though custom has sanctioned this term,
the affection here considered has probably nothing whatever to do with
rheumatism, but is an arthritis or synovitis of a septic nature, due to in-
fection from the urethral discharge. It occurs either during an acute
attack of gonorrhoea, or, more commonly, as the attack subsides, or when
it has become chronic It is far more frequent in men than in women.
It is liable to recur, and is an affection of extraordinary obstinacy. It
may involve many joints, but the knees and ankles are most commonly
affected. It is peculiar in attacking certain joints which are rarely in-
volved in acute rheumatism — as the ster no-clavicular, the intervertebral,
the temporo-maxillary, and the sacro-iliac.
The anatomical changes are variable. The inflammation is often peri-
articular, and extends along the sheaths of the tendons. When effusion
occurs in the joints it rarely becomes purulent. It has more commonly
the characters of a synovitis. About the wrist and hand suppuration
sometimes occurs in the sheaths. In the bacteriological examination the
gonococci have been found in the exudate, but not invariably. They
may be present in the tissues, however, and cause an effusion which
may be sterile. It has been suggested that the simple arthritis or syn-
ovitis follows absorption of ptomaines from the urethral discharge, while
the more severe suppurating forms are due to infection with pus organ-
isms.
19
280 CONSTITUTIONAL DISEASES.
The symptoms of this disease are very variable. R. P. Howard recog-
nized five clinical forms :
{a) ArthraJfjic^ in which there are wandering pains about the joints,
without redness or swelling. These persist for a long time.
{b) Rheumatic^ in which several joints become affected, just as in sub-
acute articular rheumatism. The fever is slight ; the local inflammation
may fix itself in one joint, but more commonly several become swollen
and tender. In this form cerebral and cardiac complications may occur.
(c) Acute goiiorrlioeal arthritis^ in which a single articulation becomes
suddenly involved. The pain is severe, the swelling extensive, and due
chiefly to peri-articular oedema. The general fever is not at all propor-
tionate to the intensity of the local signs. The affection usually resolves,
though suppuration occasionally supervenes.
(d) Chronic Hydrarthrosis. — This is usually mono-articular, and is
particularly apt to involve the knee. It comes on often without pain,
redness, or swelling. Formation of pus is rare. It occurred only twice in
ninety-six cases tabulated by Nolen.
(e) Bursal and Synovial Form. — This attacks chiefly the tendons and
their sheaths and the bursas and the periosteum. The articulations may
not be affected. The bursae of the patella, the olecranon, and the tendo
Achillis are most apt to be involved.
The disease is much more intractable than ordinary rheumatism, and
relapses are extremely common. It may become chronic and last for
years. A patient under my care, at the University Hospital, Philadel-
phia, was practically bedridden for nearly ten years with his first attack,
and was carried from one health resort to another without getting much
benefit. He finally recovered sufficiently to resume work, and enjoyed
fair health for more than a year. Then he unfortunately had another
attack of gonorrhoea. The multiple arthritis recurred, and when he came
under my observation he had been ill nearly two years.
Complications. — Iritis is not infrequent and may recur with suc-
cessive attacks. The visceral complications are rare. Endocarditis, peri-
carditis, and pleurisy may occur. R. L. MacDonnell recently analyzed
twenty-seven cases of gonorrhoeal rheumatism at the ^lontreal General Hos-
pital, of which four presented signs of recent cardiac disease. Gluzinski
has collected thirty-one cases from the literature. The endocarditis is
usually simple, but occasionally there is an intense infection and ulcera-
tive endocarditis with symptoms resembling typhoid fever.
Treatment. — The salicylates are of very little service, nor do they
often relieve the pains in this affection. Iodide of potassium has also
proved useless in my hands, even given in large doses. A general tonic
treatment seems much more suitable — quinine, iron, and, in tlie chronic
cases, arsenic.
The local treatment of the joints is very important. The thermo-
cautery may be used to allay the pain and reduce the swelling. In acute
MUSCULAR RHEUMATISM. 281
cases, fixcation of the joints is very beneficial, and in the chronic forms,
massage and passive motion. The surgical treatment of this alTection, as
carried out nowa(hiys, is more satisfactory, and I have seen strikingly good
results follow incision and irrigation.
IV. MUSCULAR RHEUMATISM {Myalgia).
Definition. — A painful affection of the voluntary muscles and of the
fasciae and periosteum to which they are attached. The affection has re-
ceived various names, according to its seat, as torticollis, lumbago, pleuro-
dynia, etc.
Etiology. — The attacks follow cold and exposure, the usual condi-
tions favorable to the development of rheumatism. It is by no means cer-
tain that the muscular tissues are the seat of the disease. Many writers
claim, perhaps correctly, that it is a neuralgia of the sensory nerves of the
muscles. Until our knowledge is more accurate, how^ever, it may be con-
sidered under the rheumatic affections.
It is most commonly met with in men, particularly those exposed to
cold and whose occupations are laborious. It is apt to follow exposure to
a draught of air, as from an open window in a railway carriage. A sud-
den chilling after heavy exertion may also bring on an attack of lumbago.
Persons of a rheumatic or gouty habit are certainly more prone to this
affection. One attack renders an individual more liable to another. It is
usually acute, but may become subacute or even chronic.
Symptoms. — The affection is entirely local. The constitutional dis-
turbance is slight, and, even in severe cases, there may be no fever. Pain
is a prominent symptom. It may be constant, or may occur only when
the muscles are drawn into certain positions. It may be a dull ache or a
bruised pain, or sharp, severe, and cramp-like. It is often sufficiently in-
tense to cause the patient to cry out. Pressure on the affected part usu-
ally gives relief. As a rule, myalgia is a transient affection, lasting from
a few hours to a few days. Occasionally it is prolonged for several weeks.
It is very apt to recur.
The following are the principal varieties :
(1) Lumbago, one of the most common and painful forms, affects the
muscles of the loins and their tendinous attachments. It occurs chiefly in
workingmen. It comes on suddenly, and in very severe cases completely
incapacitates the patient, who may be unable to turn in bed or to rise from
the sitting posture.
(2) Stiff neck or torticollis affects the muscles of the antero-lateral
region of the neck. It is very common, and occurs most frequently in
the young. The person holds the head in a peculiar manner, and rotates
the whole bo.ly in attempting to turn it. Usually it is confined to one
side. The muscles at the back of the neck may also be affected.
282 CONSTITUTIONAL DISEASES.
(3) Pleurodynia involves tlie intercostal muscles on one side, and in
some instances the pectorals and serratus magnus. This is, perhaps, the
most painful form of the disease, as the chest cannot be at rest. It is more
common on the left than on the right side. A deep breath, or coughing,
causes very intense pain, and the respiratory movements are restricted on
the affected side. There may be pain on pressure, sometimes over a very
limited area. It may be difficult to distinguish from intercostal neuralgia,
in which affection, however, the pain is usually more circumscribed and
paroxysmal, and there are tender points along the course of the nerves.
It is sometimes mistaken for pleurisy, but careful physical examination
readily distinguishes between the two affections.
(4) Among other forms which may be mentioned are cephalodynia,
affecting the muscles of the head"; scapulodynia, omodynia, and dorsodynia,
affecting the muscles about the shoulder and upper part of the back. My-
algia may also occur in the abdominal muscles and in the muscles of the
extremities.
Treatment. — Rest of the affected muscles is of the first importance.
Strapping the side will sometimes completely relieve pleurodynia. No
belief is more wide-spread among the public than the efficacy of porous
plasters for muscular pains of all sorts, particularly those about the trunk.
If the pain is severe and agonizing, a hypodermic of morphia gives im-
mediate relief. For lumbago acupuncture is, in acute cases, the most effi-
cient treatment. Needles of from three to four inches in length (ordinary
bonnet-needles, sterilized, will do) are thrust into the lumbar muscles at
the seat of the pain, and withdrawn after five or ten minutes. In many
instances the relief is immediate, and I can corroborate fully the state-
ments of Ringer, who taught me this practice, as to its extraordinary and
prompt efficacy in many instances. The constant current is sometimes
very beneficial. In many forms of myalgia the thermo-cautery gives great
relief. In obstinate cases blisters may be tried. Hot fomentations are
soothing, and at the outset a Turkish bath may cut short the attack. In
chronic cases iodide of potassium may be used, and both guaiacum and
sulphur have been strongly recommended. Persons subject to this affec-
tion should be warmly clothed, and avoid, if possible, exposure to cold
and damp. In gouty persons the diet should be restricted and the alka-
line mineral waters taken freely. Large doses of nux vomica are some-
times beneficial.
V. ARTHRITIS DEFORMANS {Rheumnfoid arfhn(is).
Definition. — A chronic disease of the joints, characterized by changes
in the cartilages and synovial membranes, with periarticular formation of
bone and G^rcat deformity.
Etiology. — Long believed to be intimately associated both with gout
ARTHRITIS DEFORMANS. 2S3
and rheumatism (whence the names rheumatic gout and rlieumatoid ar-
thritis), this close relationship seems now very doubtful, since in a ma-
jority of the cases no history of either affection can be determined. It is
difficult to separate some cases from ordinary chronic rheumatism, but the
multiple form has, in all probability, a nervous origin, as suggested by J.
K. Mitchell. This view is based upon such facts as the association of the
disease with shock, worry, and grief ; the similarity of the arthritis to the
arthropathies due to disease of the cord, as in locomotor ataxia ; the sym-
metrical distribution of the lesions ; the remarkable trophic changes which
lead to alterations in the skin and nails, and occasionally to muscular
wasting out of proportion to the joint mischief. Ord regards the disease
as analogous to progressive muscular atrophy and due either to a primary
lesion in the cord or to changes the result of peripheral irritation, trau-
matic, uterine, urethral, etc. The true nature of the disease is still ob-
scure, but the neuro- trophic theory meets very many of the facts. Females
are more liable to the disease than males. In Archibald E. Garrod's table
of 500 cases there were 411 females and 89 males. It most commonly sets
in between the ages of twenty and thirty, but it may begin as late as fifty.
It occurs also in children ; within the past five years there have been at
my clinics four cases in children under twelve. The degree of deformity
may be extreme even at this early age. Hereditary influences are not
uncommon. In Garrod's cases there were in 216 instances a family history
of joint disease. Seguin has reported the occurrence of three cases in
children of the same family. It is stated that the disease is more common
in families with phthisical history. It seems to be more frequent in women
who have had ovarian and uterine trouble, or who are sterile. In this
country acute rheumatism or gout in the forebears is rare. Mental worry,
grief, and anxiety seem frequent antecedents. It is an affection quite as
common in the rich as in the poorer classes, though in England and the
continent the latter seem more prone to the disease. Though often attrib-
uted to cold or damp, and occasionally to injury, there is no evidence that
these are efficient causes.
Morbid Anatomy. — The changes in the joints differ essentially
from those of gout in the absence of deposits of urate of soda, and from
chronic rheumatism by the existence of extensive structural alterations,
particularly in the cartilages. We are largely indebted to the magnificent
work of Adams for our knowledge of the anatomy of this disease. The
changes begin in the cartilages and synovial membranes, the cells of
which proliferate. The cartilage covering the joint undergoes a peculiar
fibrillation, becomes soft, and is either absorbed or gradually thinned by
attrition, thus laying bare the ends of the bone, which become smooth
])olished, and eburnated. At the margins, where the pressure is less, the
proliferating elements may develop into irregular nodules, which ossifiy
and enlarge the heads of the bones, forming osteophytes which completely
lock the joint. The periosteum may also form new bone. There is usu-
2S4 COXSTITUTIOXAL DISEASES.
ally great thickening of the ligaments, and finally complete anchylosis
results. This is rarely, however, a true anchylosis, but is caused by the
osteophytes and thickened ligaments. There are often hyperostosis and
increase in the articular ends of the bone in length and thickness. In
long-standing cases and in old persons there may, on the other hand, be
great atrophy of the heads of the affected bones. The spongy substance
becomes friable, and in the hip-joint the wasting may reach such an
extreme grade that the articulating surface lies between the trochanters.
This is sometimes called morbus coxce senilis. The anatomical changes
may lead to great deformity. The metacarpal joints are enlarged and
thickened, and the fingers are deflected toward the ulnar side. The toes
often show a similar deflection.
The muscles become atrophied, and in some cases the wasting reaches
a high grade. Neuritis has been demonstrated in the nerves about the
joints.
Symptoms. — Charcot makes a convenient division of the cases into
Heberden's nodosities, the general progressive form, and the partial or
mono-articular form.
Heberd&n's Nodosities. — In this form the fingers are affected, and little
hard nodules develop gradually at the sides of the distal phalanges. They
are much more common in women than in men. They begin usually be-
tween the thirtieth and fortieth year. The subjects may be in perfect
health, though more commonly they have digestive troubles, neuralgia, or
rheumatic pains, or have had gout. Although these nodules are usually
regarded as gouty, in many cases no manifestations of this disease occur.
Heberden did not lay any stress upon the association. In the early stage
the joints may be swollen, tender, and slightly red, particularly when
knocked. The attacks of pain and swelling may come on in the joints at
lonsr intervals or follow indiscretion in diet. The little tubercles at the
sides of the dorsal surface of the second phalanx increase in size, and give
the characteristic appearance to the affection. The cartilages also become
soft, and the ends of the bones eburnated. The condition is not curable ;
but there is this hopeful feature — the subjects of these nodosities rarely
have involvement of the larger joints. They have been regarded, too, as
an indication of longevity. Charcot states that in women with these
nodes cancer seems more frequent.
General Progressive Form. — This occurs in two varieties, acute and
chronic. Tlie acute form may resemble, at its outset, ordinary articular
rheumatism. There is involvement of many joints; swelling, particularly
of the synovial sheatlis and bursa? ; not often redness ; but there is mod-
erate fever. Howard describes this condition as most frequent in young
women from twenty to thirty years of age, often in connection with recent
delivery, lactation, or rapid child-bearing. Acute cases may develop at
the menopause. It may also come on in children. *' These patients suffer
in their general health, become weak, pale, depressed in spirits, and lose
ARTIIUITIS DEFORMANS. 2S5
flesh. In several cases of this form marked intervals of improvement have
occurred ; the local disease has ceased to progress, and tolerable comfort
has been experienced perhaps until pregnancy, delivery, or lactation again
determine a fresh outbreak of the disease."
The chronic form is by far the most common. The joints are usually
involved symmetrically. The first symptoms are pain on movement and
slight swelling, which may be in the joint itself or in the peri-articular
sheaths. h\ some cases the effusion is marked, in others slight. The
local conditions vary greatly, and periods of improvement alternate with
attacks of swelling, redness, and pain. At first only one or two joints are
affected ; usually the joints of the hands, then the knees and feet ; gradu-
ally other articulations are involved, and in extreme cases every articula-
tion in the body is affected. Pain is an extremely variable symptom.
Some cases proceed to the most extreme deformity without pain ; in
others the suffering is very great, particularly at night and during the
exacerbations of the disease. There are cases in which pain of an agoniz-
ing character is an almost constant symptom, requiring for years the use
of morphia.
Gradually the shape of the joints is greatly altered, partly by the pres-
ence of osteophytes, partly by the great thickening of the capsular liga-
ments, and still more by the retraction of the muscles. In moving the
affected joint crepitation can be felt, due to the eburnation of the articular
surfaces. Ultimately the joints become completely locked, not by a true
bony anchylosis, but by the osteophytes which form around the articular
surfaces, like ring-bone in horses. There is also a spurious anchylosis,
caused by the thickening of the capsular ligaments and fibrous adhesions.
The muscles about the joints undergo important changes. Atrophy from
disuse gradually supervenes, and contractures tend to flex the thigh upon
the abdomen and the leg upon the thigh. There are cases with rai3id
muscular wasting, symmetrical involvement of the joints, and trophic
changes, which strongly suggest a central origin. Numbness, tingling,
pigmentation or glossiness of the skin, and onychia may be present. In
extreme cases the patient is completely helpless, and lies on one side with
the legs drawn up, the arms fixed, and all the articulations of the extremi-
ties locked. Fortunately, it often happens in these severe general cases
that the joints of the hand are not so much affected, and the patient may
be able to knit or to write, though unable to walk or to use the arms. It
is surprising indeed how much certain patients with advanced arthritis
deformans can accomplish. No one who had seen the beautiful models
and microscopic preparations of the late 11. D. Schmidt, of New Orleans,
could imagine that he had been afflicted for years with a most extreme
grade of this terrible disease. In many cases, after involving two or
three joints, the disease becomes arrested, and no further development
occurs. It may be limited to the wrists, or to the knees and wrists, or
to the knees and ankles. A majority of the patients finally reach a
286 CONSTITUTIONAL DISEASES.
quiescent stage, in wliich they are free from pain and enjoy excellent
health, suffering only from the inconvenience and crippling necessarily
associated with the disease.
Coincident affections are not uncommon. In the active stage the pa-
tients are often anaemic and suffer from dyspepsia, which may recur at
intervals. There is no tendency to involvement of the heart.
The partial or mono-articular form affects chiefly old persons, and is
seen particularly in the hip, the knee, the spinal column, or shoulder. It
is, in its anatomical features, identical with the general disease. In the
hip and shoulder the muscles early show wasting, and in the hip the con-
dition ultimately becomes that already described as 7norbus cooccb senilis.
These cases seem not infrequently to follow an injury. They differ from
the polyarticular form in occurring chiefly in men and at a later period of
life. One of the most interesting forms affects the vertebrae, completely
locking the articulations, and producing the condition known as spondy-
litis deformans. When the cervical spine is involved the head cannot
be moved up and down, but is carried stiffly. Usually rotation can be
effected. The dorsal and lumbar spines may also be involved, and the
body cannot be flexed in the slightest degree. No other joints may be
affected.
Diagnosis. — Arthritis deformans can rarely be mistaken for either
rheumatism or gout. It is important to distinguish from the mono-articu-
lar form the local arthritis of the shoulder-joint which is characterized by
pain, thickening of the capsule and of the ligaments, wasting of the
shoulder-girdle muscles, and sometimes by neuritis. This is an affection
which is quite distinct from arthritis deformans, and is, moreover, in a
majority of cases curable.
Treatment. — Arthritis deformans is an incurable disease. In many
cases, after involvement of two or three joints, the progress is arrested.
Too often it invades successively all the articulations, and in ten, fifteen,
or twenty years the crippling becomes general and permanent.
The best that can be hoped for is a gradual arrest. It is useless to
saturate the patients with iodide of potassium, salicylates, or quinine.
Arsenic seems to do good as a general tonic. The improvement may be
marked if large doses of it are given. Iron should be used freely, if
there is anaemia. Careful attention to the digestion, plenty of good food,
and fresh air are important measures. Hydrotherapy, with carefully per-
formed massage, is best for the alleviation of the pain, and may possibly
restrain the progress of the affection. In early cases local improvement
and often great gain in the general strength follow a prolonged treat-
ment at the hot mineral baths; but the practitioner should exercise care
in recommending this mode of treatment, which is of very doubtful value
when the disease is well established. I have repeatedly known cases to be
rendered much worse by residence at these institutions. When good
results, it is largely from change of scene and climate, and the careful
GOUT. 287
resftilation of the diet. The local treatment is of benefit in arrestinor the
progress. When there are much heat and pain the limb should be at rest,
cold compresses applied at night, the joints wrapped in oiled silk, and in
the morning thoroughly massaged. It is surprising how much can be
done by carefully applied friction to reduce the thickening, to promote
absorption of effusion, and to restore mobility. Massage is also of special
benefit in maintaining the nutrition of the muscles, which early tend to
atrophy. In the case of the knees this mode of treatment will sometimes
prevent the retraction of the muscles and the gradual flexion of the legs
on the thighs. No benefit can be expected from electricity.
VI. GOUT {Podagra.)
Definition. — A nutritional disorder, associated with an excessive
formation of uric acid, and characterized clinically by attacks of acute
arthritis, by the gradual deposition of urate of soda in and about the joints,
and by the occurrence of irregular constitutional symptoms.
Etiology. — It is now generally recognized that the disease depends
upon disturbed metabolism ; most probably upon defective oxidation of
nitrogenous food-stuffs.
Among important etiological factors in gout are the following :
{a) Hereditary Influences. — Statistics show that in from fifty to sixty
per cent of all cases the disease existed in the parents or grandparents.
The transmission is supposed to be more marked from the male side.
Cases with a strong hereditary taint have been known to develop before
puberty. The disease has been seen even in infants at the breast. Males
are more subject to the disease than females. It rarely develops before
the thirtieth year; and in a large majority of the cases the first manifes-
tations appear before the age of fifty. {h) Alcohol is the most potent
factor in the etiology of the disease. Fermented liquors favor its develop-
ment much more than distilled spirits, and it prevails most extensively in
countries like England and Germany, which consume the most beer and
ale. Probably the greater tendency of malt liquors to induce gout is asso-
ciated with the production of an acid dyspepsia. The lighter beers used
in this country are much less liable to produce gout than the heavier Eng-
lish and Scotch ales, {c) Food plays a role equal in importance to that of
alcohol. From the time of Hippocrates overeating has been regarded as
a special predisposing cause. The excessive use of food, particularly of
meats, disturbs gastric digestion and leads to the formation of lactic and
volatile fatty acids. It is held by Garrod and others that these tend to de-
crease the alkalinity of the blood and to reduce its power of holding urates
in solution. A special form of gouty dyspepsia has been described. A
robust and active digestion is, however, of ten met in gouty persons. Gout
is by no means confined to the rich. In England the combination of
288 CONSTITUTIONAL DISEASES.
poor food, defective hygiene, and an excessive consumption of malt liquors
makes the " poor man's gout " a common affection, (d) Lead. Garrod
has shown tliat workers in lead are specially prone to gout. In thirty
per cent of his hospital cases the patients had been painters or workers in
lead. The association is probably to be sought in the production by this
poison of arterio-sclerosis and chronic nephritis. Something in addition
is necessary, or certainly in this country we should more frequently see
cases of the kind so common in London hospitals. Chronic lead-poison-
ing is here frequently associated with arterio-sclerosis and contracted kid-
neys, but acute arthritis is rare. Gouty deposits are, however, to be found
in the big-toe joint and in the kidneys in these cases.
There are three theories with reference to gout :
(1) 7'he Uric-acid TJieory. — Sir Alfred Garrod, to whom the profession
is indebted for so many careful studies in this disease, showed that there
was an increase in the uric acid in the blood, due either to increased pro-
duction or to diminished elimination ; and that the alkalinity of the blood
was also lessened. He attributes the deposition of the urate of soda to
the diminished alkalinity of the plasma, which is unable to hold it in solu-
tion. An increase in the quantity of the uric acid produced, or any inter-
ference with elimination through the kidneys, may cause a sudden out-
break. The acute paroxysm is due to an accumulation of the urates in
the blood, which he believes are responsible also for the preliminary dys-
pepsia, the coated tongue, the irritability of temper, and the general feel-
ings of malaise. The sudden deposit of the crystalline urates about the
joint leads to inflammation.
(2) The Nervous Theory. — The view of Cullen that gout was primarily
an affection of the nervous system has been modified into a neuro-humoral
view w^hich has been advocated particularly by Sir Dyce Duckworth. On
this theory there is a basic, arthritic stock — a diathetic habit, of which
gout and rheumatism are two distinct branches. The gouty diathesis is
expressed in (a) a neurosis of the nerve-centres, which may be inherited or
acquired ; and {b) " a peculiar incapacity for normal elaboration within
the whole body, not merely in the liver or in one or two organs, of food,
whereby uric acid is formed at times in excess, or is incapable of being
duly transformed into more soluble and less noxious products " (Duck-
worth). 'J'he explosive neuroses and the influence of depressing circum-
stances, physical or mental, point strongly to the part played by the nerv-
ous system in the disease.
(3) Fjhsteiii's Theory. — A nutritive tissue disturbance is the primary
change leading to necrosis, and in the necrotic areas the urates are de-
posited. Tliis is not unlike the view of Ord, who holds that there is
a tendency, inherited or acquired, to a special form of tissue degenera-
tion.
Morbid Anatomy. — The hlood shows an excess of uric acid, as
proved originally by Garrod. The uric acid may be obtained from the
GOUT. 289
blood-serum by the method known as uric-acid thread experiment, or from
the serum obtained from a blister. To 3 ij of serum add ttiv-vj of acetic
acid in a watch-glass. A thread immersed in this will show in a few
hours an incrustation of uric acid. This is not, however, peculiar to gout,
but occurs in leuka3mia and chlorosis. The important changes are in the
articular tissues. The first joint of the great toe is most frequently in-
volved; then the ankles, knees, and the small joints of the hands and
wrists. The deposits may be in all the joints of the lower limbs and
absent from those of the upper limbs (Norman Moore). If death takes
place during an acute paroxysm, there are signs of inflammation, hyperae-
mia, swelling of the ligamentous tissues, and of effusion into the joint.
The primary change, according to Ebstein, is a local necrosis, due to the
presence of an excess of urates in the blood. This is seen in the cartilage
and other articular tissues in which the nutritional currents are slow. In
these areas of coagulation necrosis the reaction is always acid and the
neutral urates are deposited in crystalline form, as insoluble acid urates.
The articular cartilages are first involved. The gouty dej)Osit may be uni-
form, or in small areas. Though it looks superficial, the deposit is in-
variably interstitial and covered by a thin lamina of cartilage. The de-
posit is thickest at the part most distant from the circulation. The liga-
ments and fibro-cartilage ultimately become involved and are infiltrated
with chalky deposits, the so-called chalk-stones, or tophi. These are usu-
ally covered by skin ; but in some cases, particularly in the metacarpo-
phalangeal articulations, this ulcerates and the chalk-stones appear ex-
ternally. The synovial fluid may also contain crystals. In very long-
standing cases, owing to an excessive deposit, the joint becomes immobile.
The marginal outgrowths in gouty arthritis are true exostoses (Wynne).
The "cartilage of the ear may contain tophi, which are seen as yellowish
nodules at the margin of the helix. The cartilages of the nose, eyelids,
and larynx are less frequently affected.
Of changes in the internal organs, those in the renal and vascular sys-
tems are the most important. The kidney changes believed to be charac-
teristic of gout are : (a) A deposit of urates chiefly in the region of the
papillae. I'his is a less common change, however, than is usually sup-
posed. Norman Moore found it in only twelve out of eighty cases. The
apices of the pyramids show lines of whitish deposit. On microscopical
examination the material is seen to be largely in the intertubular tissue.
In some instances, however, the deposit seems to be both in the tissue and
in the tubules. Ebstein, in his monograph, has described and figured
areas of necrosis in both cortex and medulla, in the interior of which were
crystalline deposits of urate of soda. The presence of these uratic con-
cretions at the apices of the pyramids is not a positive in iication of gout.
They are not infrequent in this country, in which gout is rare, (/y) An
interstitial nephritis, either the ordinary "contracted kidney" or the
arterio-solerotic form, neither of which are in any way distinctive. It is
290 COXSTITTTIOXAL DISEASES.
not possible to say in a given case tliat the condition has been due to gout
unless marked evidences of the disease coexist.
The metatarso-phalangeal joint of the big toe should be carefully ex-
amined, as it may show typical lesions of gout without any outward token
of arthritis.
Arterio-sclerosis is a very constant lesion. "With it the heart, particu-
larly the left ventricle, is found hypertrophied. According to some au-
thors, concretions of urate of soda may occur on the valves.
Changes in the respiratory system are rare. Deposits have been found
in the vocal cords, and uric-acid crystals have been met in the sputa of a
gouty patient (J. W. Moore). Emphysema is a very constant condition
in old cases.
Symptoms. — Gout is usually divided into acute, chronic, and irregu-
lar forms.
Acute Gout. — Premonitory symptoms are common — twinges of pain
in the small joints of the hands or feet, nocturnal restlessness, irrita-
bility of temper, and dyspepsia. The urine is acid, scanty, and high-
colored. It deposits urates on cooling, and there may be, according to
Garrod, transient albuminuria. There may be traces of sugar (gouty gly-
cosuria). Before an attack the output of uric acid is low and is also di-
minished in the early part of the paroxysm. In some instances the throat
is sore, and there may be asthmatic attacks. The attack sets in usually
in the early morning hours. The patient is aroused by a severe pain in
the metatarso-phalangeal articulation of the big toe, and more commonly
on the right than on the left side. The pain is agonizing, the joint swells
rapidly, and becomes hot, tense, and shiny. The sensitiveness is extreme,
and the patient describes the pain as if the joint were being pressed in a
vice. There is fever, and the temperature may rise to 102° or 103°.
Toward morning the severity of the symptoms subsides, and, although the
joint remains swollen, the day may be passed in comparative comfort.
The symptoms recur the next night, and the fit, as it is called, usually lasts
for from five to eight days, the severity of the symptoms gradually abating.
Occasionally other joints are involved, particularly the big toe of the op-
posite foot. The inflammation, however intense, never goes on to suppu-
ration. With the subsidence of the swelling the skin desquamates. After
the attack the general health may be much improved. Recurrences are
frequent. Some patients have three or four attacks in a year ; others at
longer intervals. Lecorche has shown that the amount of uric acid is
reduced prior to an attack, diminishes during the first two days, then in-
creases very much and falls toward the close.
The term retroccdent or svppvpsscd gout is applied to serious internal
symptoms, coincident with a ra])id disappearance or improvement of the
local signs. Very remarkable manifestations may occur under these cir-
cumstances. The patient may have severe gastro-intestinal symptoms —
pain, vomiting, diarrhoea, and great depression — and death may occur
GOUT. 291
daring such an attack. Or there may be cardiac manifestations — dyspna'a,
pain, and irregular action of tlie heart. In some instances in which the
gout is said to attack the heart, an acute pericarditis develops and proves
fatal. So, too, there may be marked cerebral manifestations — delirium
and coma, and even apoplexy — but in a majority of these instances the
symptoms are, in all probability, ur^emic.
Acute gout is a rare disease in America, and in hospital practice is
almost unknown. Among the well-to-do and even among club-men — a
class particularly liable — it is infrequent, in comparison with the preva-
lence in the corresponding classes in England. Men in large family prac-
tice may pass a year or more without seeing a case. It has become more
common, however, during the past twenty-five years.
Chronic Gout. — With increased frequency in the attacks, the articular
symptoms persist for a longer time, and gradually many joints become
affected. Deposits of urates take place, at first in the articular cartilages
and then in the ligaments and capsular tissues ; so that in the course of
years the joints become swollen, irregular, and deformed. The feet are
usually first affected, then the hands. In severe cases there may be exten-
sive concretions about the elbows and knees and along the tendons and in
the bursae. The tophi appear in the ears. Finally, a unique clinical pict-
ure is produced which cannot be mistaken for any other affection. The
skin over the tophi may rupture or ulcerate, and about the knuckles the
chalk-stones may be freely exposed. Patients with chronic gout are usu-
ally dyspeptic, often of a sallow complexion, and show signs of arterio-
sclerosis. The pulse tension is increased, the vessels are stiff, and the left
ventricle is hypertrophied. The urine is increased in amount, is of low
specific gravity, and usually contains a slight amount of albumen, with a
few hyaline casts.' Patients with chronic gout may show remarkable
mental and even bodily vigor. Certain of the most distinguished mem-
bers of our profession have been terrible sufferers from this disease — nota-
bly the elder Scaliger, Jerome Cardan, and Sydenham, whose statement
that " more wise men than fools are victims of the affection " still holds
good.
Irregular Gout. — This is a motley, ill-defined group of symptoms,
manifestations of a condition of disordered nutrition, to which the terms
gouty diathesis or UtlLcemic state have been given. Cases are seen in mem-
bers of gouty families, who may never themselves have suffered from the
acute disease, and in persons who have lived not wisely but too well, wlio
have eaten and drunk largely, lived sedentary lives, and yet have been for-
tunate enough to escape an acute attack. It is interesting to note the
various manifestations of the disease in a family with marked hereditary
disposition. The daughters often escape, while one son may have gouty
attacks of great severity, even though he lives a temperate life and tries
in every way to avoid the conditions favoring the disorder. Another son
has, perhaps, only the irregular manifestations and never the acute articu-
292 CONSTITUTIONAL DISEASES.
lar affection. Wliilc the irregular features are perhaps more often met
with in the hereditary affection, they are by no means infrequent in per-
sons wlio appear to have acquired the disease. The tendency in some
families is to call every affection gouty. Even infantile com2)laints, such
as scald-head, naso-pharyngeal vegetations, and enuresis, are often re-
garded, without sufficient grounds, I believe, as evidences of the family
ailment. Among the commonest manifestations of irregular gout are the
following :
{a) Cutaneous Eruptions. — Garrod and others have called special
attention to the frequent association of eczema with the gouty habit.
The French in particular insist upon the special liability of gouty persons
to skin affections, the arthritides^ as they call them.
(h) Gastro-intestinal Disorders. — Attacks of what is termed bilious-
ness, in which the tongue is furred, the breath foul, the bowels consti-
pated, and the action of the liver torpid, are not uncommon in gouty
persons.
{c) Cardio-vascular Symj^toms. — With the lithtemia, arterio-sclerosis is
frequently associated. The blood tension is persistently high, the vessel
walls become stiff, and cardiac and renal changes gradually develop. In
this condition the manifestations may be renal, as when the albuminuria
becomes more marked, or dropsical symptoms supervene. The manifesta-
tions may be cardiac, when the hypertrophy of the left ventricle fails and
there are palpitation, irregular action, and ultimately a condition of asystole.
Or, finally, the manifestations may be vascular, and involvement of the
coronary arteries may cause sudden death. Aneurism may develop and
prove fatal, or, as most frequently happens, a blood-vessel gives way in the
brain, and the patient dies of apoplexy. It makes but little difference
whether we regard this condition as primarily an arterio-sclerosis or as a
gouty nephritis; the point to be remembered is that the nutritional dis-
order with which an excess of uric acid is associated induces in time in-
creased tension, arterio-sclerosis, chronic interstitial nephritis, and changes
in the myocardium. Pericarditis is not infrequent in connection with
the granular kidney met with in gout.
{d) Cerebral Manifestations. — Headache is frequent. Haig has called
special attention to the association of this symptom with retention of uric
acid in the system. Neuralgias are not uncommon ; sciatica and paraes-
thesias may develop. A common gouty manifestation, upon which Duck-
worth has laid stress, is the occurrence of hot or itching feet at night.
Cramps in the legs may also be very troublesome. Hutchinson has called
attention to hot and itching eyeballs as a frequent sign of masked gout.
More serious cerebral manifestations result from a condition of arterio-
sclerosis. Apoplexy is a common termination of gout. A low meningitis
may develop, usually basilar.
(r) Urinary Disorders. — The urine is highly acid and high-colored,
and may deposit on standing crystals of lithic acid. Transient and tern-
GOUT. 293
porary increase in this ingredient cannot be regarded as serious. In many
cases of chronic gout the amount nuiy be diminished, and only increased
at certain periods, forming tlie so-called uric-acid showers. Sugar is found
intermittently in the urine of gouty persons — gouty glycosuria. It may
pass into true diabetes, but is usually very amenable to treatment. Oxaluria
may also be present Gouty persons are specially prone to calculi, Jerome
Cardan to the contrary, who reckoned freedom from stone among the chief
of the dona idodagrm. Minute quantities of albumen are very common in
persons of gouty dyscrasia, and, when the renal changes are well estab-
lished, tube-casts. Urethritis, accompanied with a well-marked purulent
discharge, may develop, so it is stated, usually at the end of an attack. It
may occur spontaneously, or follow a pure connection.
(/) Pulmonary Disorders. — There are no characteristic changes, but,
as Greenhow has pointed out, chronic bronchitis occurs with great fre-
quency in persons of a gouty habit.
{g) Of eye affections, iritis, glaucoma, haemorrhagic retinitis, and sup-
purative panopthalmitis have been described.
Treatment. — Individuals who have inherited a tendency to gout, or
who have shown any manifestations of it, should live temperately, abstain
from alcohol, and eat moderately. An open-air life, with plenty of exer-
cise and regular hours, does much to counteract an inborn tendency to
the disease.
Diet. — Experience has shown that a modified nitrogenous diet is the
most suitable. Starchy and saccharine articles of food are to be taken in
very limited quantities ; as " the conversion of azotized food is more com-
plete with a minimum of carbohydrates than it is with an excess of them
— in other words, one of the best means of avoiding the accumulation of
lithic acid in the blood is to diminish the carbohydrates rather than the
azotized foods" (Draper). Meats of all kinds, except perhaps the coarser
sorts, such as pork and veal, and salted provisions, may be used. Eggs,
oysters, and fish may be taken. Lobsters and crabs, particularly when
made into salads, are to be eschewed. The sugar should be reduced to a
minimum. The sweeter fruits should not be taken. Oranges and lemons
may be allowed. Strawberries, bananas, and melons should not be eaten.
If necessary, saccharin may be substituted for cane sugar. Potatoes
should be sparingly used. The fresh vegetables, such as lettuce, cucum-
bers, tomatoes, and cauliflower, may be taken freely. Hot rolls and cakes
of all sorts, hominy, grits, and the more starchy forms of prepared foods
are not suitable. The various articles of diet prepared from corn should
be avoided. Fats are easily digested and may be taken freely. In obsti-
nate cases great benefit is derived from an exclusively milk diet.
Persons with a gouty tendency should be encouraged to drink freely
of such mineral waters as they prefer. They keep the interstitial circula-
tion active and so favor elimination. Milk and i)otash-water form a pleas-
ant and wholesome drink for a lithaemic patient. Alcohol in all forms
294: CONSTITUTIONAL DISEASES.
should be avoided. When from any cause a stimulant is indicated, claret,
dry sherry, or good whisky is preferable. Champagne is particularly per-
nicious. Persons with a marked tendency to lithasmia should be urged to
restrict the appetite and to take only a moderate amount of food. Over-
eating is not far behind excessive drinking in its injurious effects. In-
deed, a majority of people over forty years of age take more food than is
required to maintain the equilibrium of health. Gout, in many cases,
is evidence of an overfed, overworked, and consequently clogged ma-
chine.
The skin should be kept active : if the 2:)atient is robust, by the morn-
ing cold bath wuth friction after it ; but if weak or debilitated, the even-
ing warm bath should be substituted. An occasional Turkish bath with
active shampooing is advantageous. The secretion of urine should be
fully maintained, and the specific gravity reduced by diluents to at least
1-015. The bowels should be kept open and an occasional saline purga-
tive may be administered. The patient should dress warmly, avoid rapid
alterations in temperature, and be careful not to have the skin suddenly
chilled. Gouty persons derive much benefit from taking certain waters,
such as Saratoga, the Bedford, the White Sulphur of Virginia, in this
country ; the Bath and Harrogate, in England ; and those of Carlsbad,
Kissingen, Homburg, Vichy, and Contrexeville, on the continent.
In an acute attack the limb should be elevated and the affected joint
wrapped in cotton-wool. Warm fomentations, or Fuller's lotion, may be
used. Steaming the joint is sometimes beneficial. A brisk mercurial
purge is always advantageous at the outset. The wine or tincture of col-
chicum, in doses of twenty to thirty minims, may be given every four
hours in combination with the citrate of potash or the citrate of lithium.
The colchicum should be carefully watched. It has, in a majority of the
cases, a powerful influence over the symptoms ; relieving the pain and
reducing, sometimes with great rapidity, the swelling and redness. It
should be promptly stopped as soon as it has relieved the pain. In cases
in which the pain and sleeplessness are more distressing and do not yield
to colchicum, morphia may be necessary. The patient should be placed
on a low diet, chiefly of milk and barley-water, but if there is any de-
bility, strong broths may be given, or eggs. It is occasionally necessary
to give small quantities of stimulants. Potash water, Apollinaris, or
Seltzer water should be taken freely. Waters with the sodium salts
should be avoided. During convalescence meats and fish and game may
be taken, and gradually the patient may resume the diet previously laid
down.
In the chronic and irregular forms of gout the treatment by hygiene
and diet is most suitable. Colchicum is not often required, though in
small doses it is sometimes beneficial. Lithium salts do good, since a
combination of uric acid with lithium is more soluble than the sodium
salt. There is no good native litliia water. The medicine is best given
DIABETES MELLITUS. 295
in potash water, in a glassful of which five grains of the citrate of lithium
may be taken three times a clay, or the liquor lithicB effervescens of the
British Pharmacop(joia may be used. The mineral waters above men-
tioned are particularly beneficial, partly in themselves, and partly owing
to the strict regulations to which the patient is subjected Avhen taking the
"cure." Ammoniacum, guaiacum, and preparations of quinine and iron
are sometimes serviceable in the chronic gout. Iodide of potassium and
the benzoates are also recommended. The local treatment of joints affect-
ed with chronic gout is not satisfactory. Hydrotherapeutic measures, the
Paquelin, and massage may be tried.
VII. DIABETES MELLITUS.
Definition. — A disorder of nutrition, in which sugar accumulates
in the blood and is excreted in the urine, the daily amount of which is
greatly increased.
Etiology. — Hereditary influences play an important role^ and cases
are on record of its occurrence in many members of the same family.
There are instances of the coexistence of the disease in husband and
wife. Men are more frequently affected than women. It is a disease of
adult life ; a majority of the cases occur from the third to the sixth decade.
It is rare in childhood, but cases are on record in children under one year
of age. Persons of a neurotic temperament are often affected. It is a
disease of the higher classes. Hebrews seem especially prone to it ; one
fourth of Frerichs' cases were of the Semitic race. In a considerable pro-
portion of the cases of diabetes the subjects have been excessively fat at
the beginning of, or prior to, the onset of the disease. It must be remem-
bered, however, that a slight trace of sugar is not very uncommon in obese
persons. This so-called lipogenic glycosuria is not of grave significance,
and is only occasionally followed by true diabetes. There are instances
on record in which obesity with diabetes has occurred in three genera-
tions. It is more common in cities than in country districts. Gout,
syphilis, and malaria have been regarded as predisposing causes. Mental
shock, severe nervous strain, and worry precede many cases. The combi-
nation of intense application to business, over-indulgence in food and
drink, with a sedentary life, seem particularly prone to induce the disease.
It may set in during pregnancy, and in rare instances may only occur at
this period. Injury to or disease of the spinal cord or brain has been
followed by diabetes. In the carefully analyzed cases of Frerichs there
were thirty instances of organic disease of these parts. The medulla is
not always involved. In only four of his cases, which showed organic dis-
ease, was there sclerosis or other anomaly of this part. An irritative lesion
of Bernard's diabetic centre in the medulla is an occasional cause. I saw
with Riess, at the Friedriohshain, Berlin, a woman who had anomalous
20
296 CONSTITUTIONAL DISEASES.
cerebral symptoms and diabetes, and in whom there was found post mor-
tem a cysticercus in the fourth ventricle.
Of late years lesions of the pancreas have been held to cause diabetes,
and in a certain number of cases this organ is affected. The disease has oc-
casionally followed the infectious fevers. A few cases have followed injury
without involvement of the brain or cord.
In comparison with European countries diabetes is a rare disease in
America. The last census gave only 2*8 per one hundred thousand of
population, against a ratio of from five to nine in the former. In this
region the incidence of the disease may be gathered from the fact that
among thirty-five thousand patients under treatment at the Johns Hop-
kins Hospital and Dispensary there were only ten cases.
We are ignorant of the nature of the disease. Normally the carbo-
hydrates taken with the food are stored in the liver as glycogen, and then
utilized as needed by the system. Glycogen can also be formed from the
proteidsof the food, and under certain circumstances sugar may be direct-
ly formed from the body proteids. Whenever the sugar in the systemic
blood exceeds a definite amount it is discharged by the kidneys, producing
glycosuria. Theoretically the condition may be supposed to be induced by :
(a) The ingestion of a larger quantity of carbohydrates and peptones
than can be warehoused, so to speak, in the liver as glycogen, so that
part has to pass over into the hepatic blood. Some of the instances of
lipogenic or dietetic glycosuria are of this nature.
(b) Disturbances of the liver function : (1) Changes in the circula-
tion under nervous influences. Puncture of the medulla, lesions of the
cord, and central irritation of various kinds are followed by glycosuria,
which is attributed to a vaso-motor paralysis (more rapid blood-flow) in-
duced by these causes. On this view the disease is a neurosis. (2) In-
stability of the glycogen, owing either to imperfect formation or to con-
ditions of the cells which render it less stable. Phloridzin and other
substances which cause diabetes very probably act in this way.
(c) Defective assimilation of the glucose in the system. How and
under what normal circumstances the sugar is utilized we do not yet
know. Theoretically faulty metabolism would ex])lain the condition.
Interesting observations have of late made it probable that the pancreas
may in some cases be the seat of the trouble. Lesions of this organ have
frequently been met with in diabetes. Von Mering and Minkowski have
shown that extirpation of the gland in dogs is followed by glycosuria, but,
if a small portion remains, sugar does not appear in the urine, facts which
have been confirmed by Lopine and others. Tlie pancreas, on this view,
has, like the liver, a double secretion — an external, which is poured into
the intestines, and an internal, which passes into the blood. This latter
is supposed to be of the nature of a ferment, in the presence of which
alone the normal assimilative processes can take place with the glycogen.
Disease of the pancreas causes diabetes by preventing the formation of
DIABETES MELLITUS. 2t)7
the glycolytic ferment. Even when, as in a majority of instances of
diabetes, the organ is apparently normal, a functional trouble may disturb
the formation of this ferment. The fact that if a small portion of the
gland is left, in the experiments upon dogs, diabetes does not occur, is
analogous to the remarkable circumstance that a small fragment of the
thyroid is sufficient to prevent the development of articifial myxoedema.
It has recently been stated by Falkenberg that extirpation of the thyroid
gland in dogs is also followed by diabetes.
Morbid Anatomy. — Saundby * has recently analyzed the changes
which occur in this disease.
The nervous system shows no constant lesions. In a few instances
there have been tumors or sclerosis in the medulla, or, as in the case above
mentioned, a cysticercus has pressed on the floor. Cysts have been met
with in the white matter of the cerebrum and perivascular changes have
been described. Glycogen has been found in the spinal cord. In the
peripheral nervous system there are instances in which tumors have been
found pressing on the vagus. A secondary multiple neuritis is not rare,
and to it the so-called diabetic tabes is probably due.
In the sympathetic system the ganglia have been enlarged and in some
instances sclerosed, but there is nothing peculiar in these changes. The
blood may contain as high as 0*4 per cent of sugar instead of 0*15 per cent.
The plasma is usually loaded with fat, the molecules of which may be seen
as fine particles. When drawn, a white creamy layer coats the coagulum,
and there may be lipaemic clots in the small vessels. There are no special
changes in the red or white corpuscles. Gabritschewsky has shown that
the " polynuclear " leucocytes in diabetes contain glycogen. Glycogen can
occur in normal blood, but it is here extra-cellular. It has been also
found in the polynuclear leucocytes in leukaemia. The heart shows no
characteristic changes. Endocarditis is very rare. The lu7igs show im-
portant changes. x\cute broncho-pneumonia or croupous pneumonia
(either of which may terminate in gangrene) and tuberculosis are com-
mon. The so-called diabetic phthisis is always tuberculous and results
from a caseating broncho-pneumonia. In rare cases there is a chronic
interstitial pneumonia, non-tuberculous. Fatty embolism of the pulmo-
nary vessels has been described in connection with diabetic coma.
The liver is usually enlarged, fatty degeneration is common, and
French writers have described a form of cirrhosis. Letulle, who has de-
scribed remarkable examples of this so-called diabetic cirrhosis — the cir-
rhose pign-ientaire — thinks the change is due to abnormal destruction of
the blood-cells. It may be associated with bronzing of the skin.
Tha pancreas^ as pointed out by Lancereaux, shows important changes.
Saundby states that in seven out of fifteen cases it was atrophied, abnor-
* Bradshaw Locturo, Royal Collepfoof Physicians of London, 1890; and Lectures on
Diabetes, E. B. Treat, New York, 1891.
298 CONSTITUTIONAL DISEASES.
mally linn and fibroid in four, and normal in only four. A patient of "W.
T. Bull died of diabetes after extirpation of the pancreas. In some in-
stances tliere is a pigmentary cirrhosis analogous to that which occurs in
the liver, and this induration seems to be an important change. Cancer
of the pancreas has been met witli, and Longstreth found, in one instance,
cystic disease. Fat necrosis of the pancreas has also been found. Neither
the stomach nor the intestiyies show any characteristic lesions.
The kidneys are sometimes fatty, and show a hyaline change in the
tubular epithelium, particularly in the descending limb of the loop of
Ilenle. It also occurs in the capillary vessels. Saundby confirms the
occurrence of this hyaline change, and its restriction to the epithelium of
Henle's tubes.
Symptoms. — Acute and chronic forms are recognized, but there is
no essential difference between them, except that in the former the pa-
tients are younger, the course more rapid, and the emaciation more
marked.
It is also possible to divide the cases into (1) lipogenic or dietetic, which
includes the transient glycosuria of stout persons ; (2) neurotic, due to
injuries or functional disorders of the nervous system ; and (3) pancreatic^
in which there is a lesion of the pancreas. It is, however, by no means
easy to discriminate in all cases between these forms. Of late attempts
have been made to separate a clinical variety analogous to experimental
pancreatic diabetes. Ilirschfeld, from Guttmann's clinic, has described
cases running a rapid and severe course usually in young and middle-aged
persons. The polyuria is less common or even absent, and there is a strik-
ing defect in the assimilation of the albuminoids and fats, as shown by
the examination of the faeces and urine. In four of seven cases autopsies
were made and the ])ancreas was found atrophic in two, cancerous in one,
and in the fourth exceedingly soft.
The onset of the disease is gradual and either frequent micturition or
inordinate thirst first attracts attention. Very rarely it sets in rapidly,
after a sudden emotion, an injury, or after a severe chill. When fully
established the disease is characterized by great thirst, the passage of large
quantities of saccharine urine, a voracious appetite, and, as a rule, pro-
gressive emaciation.
The Urine. — The amount varies from six or eight pints in mild cases
to thirty or forty pints in very severe cases. In rare instances the quan-
tity of urine is not much increased. Under strict diet the amount is
much lessened, and in intercurrent febrile affections it may be reduced to
normal. The specific gravity is high, ranging from 1'025 to 1*045. The
urine is pale in color, almost like water, and has a sweetish odor and a dis-
tinctly sweetish taste. The reaction is acid. Sugar is present in varying
amounts. In mild cases it does not exceed one and a half or two per cent,
but it may reach from five to ten per cent. The total amount excreted
in the twenty-four hours may range from ten to twenty ounces, and in
DIABETES MELLITUS. 299
exceptional cases from one to two pounds. The following are the most
satisfactory tests :
Feliliiig^s 2'est. — The solution consists of sulphate of copper (grs. 90J),
neutral tartrate of potash (grs. 3G4), solution of caustic soda (11. ozs. 4),
and distilled water to make up six ounces. Put a drachm of this in a test-
tube and boil (to test the reagent) ; add an equal quantity of urine and boil
again, when, if sugar is present, the yellow suboxide of copper is thrown
down. The solution must be freshly prepared, as it is apt to decompose.
Trommer^s Test. — To a drachm of urine in a test-tube add a few drops
of a dilute sulphate-of-copper solution and then as much liquor potassm
as urine. On boiling, the copper is reduced if sugar be present, forming
the yellow or orange-red suboxide. There are certain fallacies in the cop-
per tests. Thus, a substance called glycuronic acid is met with in the
urine after the use of certain drugs — chloral, phenacetin, morphia, chloro-
form, etc. — which reduces copper. It has been found in the urine of an
apparently healthy man (Ashdow^n).
Fermentation Test. — This is free from all doubt. Place a small frag-
ment of yeast in a test-tube full of urine, which is then inverted over a
glass vessel containing the same fluid. If sugar is present, fermentation
goes on with the formation of carbon dioxide, which accumulates in the
upper part of the tube and gradually expels the urine.*
Of other ingredients in the urine, the urea is increased, the uric acid
does not show special changes, and the phosphates may be greatly in ex-
cess. Kalfe has described a great increase in the phosphates, and in some
of these cases, with an excessive excretion, the symptoms may be very
similar to those of diabetes, though the sugar may not be constantly pres-
ent. The term phosphatic diabetes has sometimes been applied to them.
Acetone and acetone-forming substances are not infrequently present. Le
Nobel's test for acetone is as follows : *' Pour an ounce of urine into a
urine glass ; add a drachm or two of nitro-prusside of sodium (five grains
to one ounce) and a few drops of strong liquid ammonia. After standing
a few minutes a rose-violet color is developed, which, if much acetone is
present, may require diluting with water in order to bring out the brill-
iancy of its color" (Saundby).
Glycogen has also been described as present in the urine.
Alburnen is not infrequent. It occurred in nearly thirty-seven per cent
of the examinations made by Lippman at Carlsbad.
Among the general symptoms of the disease, thirst is one of the most
distressing. A very large amount of water is required to keep the sugar
in solution and for its excretion in the urine. The amount of water con-
sumed will be found to bear a definite ratio to the quantity excreted. In-
stances, however, are not uncommon of pronounced diabetes in which the
* For quanlilativc and other tests the student is referred to Tyson, On the Urine, or
the standard works on urinalysis.
300 CONSTITUTIONAL DISEASES.
thirst is not excessive; but in such cases the amount of urine passed is
never large. The thirst is most intense an hour or two after meals. As
a rule, the digestion is good and the appetite inordinate. A story is told
of a man with diabetes who was paid to stay away from a certain restau-
rant at which dinners were given at fixed prices. It is sometimes impos-
sible to satiate the ravenous appetite of a diabetic patient. The condition
is sometimes termed hidimia or polyphagia.
The tongue is usually dry, red, and glazed, and the saliva scanty. The
gums may become swollen, and in the later stages aphthous stomatitis is
common. Constipation is the rule.
In spite of the enormous amount of food consumed a patient may be-
come rapidly emaciated. This loss of flesh bears some ratio to the poly-
uria, and when, under suitable diet, the sugar is reduced, the patient may
quickly gain in flesh. The skin is dry and harsh, and perspirations rarely
occur, except when phthisis coexists. Drenching sweats have been known
to alternate with excessive polyuria. The temperature is often subnor-
mal ; the pulse is usually frequent, and the tension increased. Many dia-
betics, however, do not show marked emaciation. Patients past the mid-
dle period of life may have the disease for years without much disturbance
of the health, and may remain well nourished. These are the cases of the
diabete gras in contradistinction to diahete maigre.
Diabetes in Children. — Eecently Stern has analyzed 117 cases in chil-
dren. They usually occur among the better classes. Six were under one
year of age. Hereditary influences were marked. The course of the dis-
ease is, as a rule, much more rapid than in adults. The shortest duration
was two days. In seven cases it did not last a month. One case is men-
tioned of a child apparently born with the glycosuria, who recovered in
eight months.
Complications. — {a) Cutaneous. — Boils and carbuncles are extreme-
ly common. Eczema is also met with and at times an intolerable itching.
In women the irritation of the urine may cause the most intense pruritus
pudendi, and in men a balanitis. Karer affections are xanthoma and pur-
pura. Gangrene is not uncommon. William Hunt has analyzed 64 cases.
In 50 the localities were as follows : Feet and legs, 37 ; thigh and buttock,
2 ; nucha, 2 ; external genitals, 1 ; lungs, 3 ; fingers, 3 ; back, 1 ; eyes, 1.
Perforating ulcer of the foot may occur.
{h) Pulmonary. — The patients are not infrequently carried off by acute
pneumonia^ which may be lobar or lobular. Gangrene is very apt to
supervene, but the breath does not necessarily have the foul odor of ordi-
nary gangrene.
TtihercAilous hronc]iO-2))iGumonia is very common. It was formerly
thought, from its rapid course and the limitation of the disease to the
lung, that this was not a true tuberculous affection ; but in the cases which
have come under my notice bacilli have been present, and the condition is
now generally regarded as tuberculous.
DIABETES MELLITUS. 301
(c) Renal. — Alhumimiria is a tolerably frequent complication. The
amount varies greatly, and, when slight, does not seem to be of much mo-
ment. It is sometimes associated with arterio-sclerosis. It occasionally
precedes the development of the diabetic coma. Occasionally cystitis
develops.
{d) Nervous System. — (1) Diabetic coma^ first studied by Kiissmaul, is
the most serious complication of the disease, and carries off a considerable
proportion of all cases, particularly in the young. It may occur when
diabetes is unsuspected, as in two cases recently reported by Francis
Minot. Frerichs recognized three groups of cases : (a) Those in which
after exertion the patients were suddenly attacked with weakness, syncope,
somnolence, and gradually deepening unconsciousness ; death occurring
in a few hours. (/8) Cases with preliminary gastric disturbance, such as
nausea and vomiting, or some local affection, as pharyngitis, phlegmon, or
a pulmonary complication. In such cases the attack begins with head-
ache, delirium, great distress, and dyspnoea, affecting both inspiration and
expiration, a condition called by Kiissmaul air-hicnger. Cyanosis may or
may not be present. If it is, the pulse becomes rapid and weak and the
patient gradually sinks into coma ; the attack lasting from one to five
days. There may be a very heavy, sweetish odor of the breath, due to the
presence of acetone, (y) Cases in which, without any previous dyspnoea
or distress, the patient is attacked with headache and a feeling of intoxi-
cation, and rapidly falls into a deep and fatal coma.
There has been much dispute as to the nature of these symptoms, but
our knowledge of the disease is not yet sufficiently advanced to give a
rational explanation. The character of the attack and the similarity, in
many instances, to uraemia would indicate that it depended upon some
toxic agent in the blood. The theory most commonly held, that this
material is acetone, is supported by the presence of the acetone reaction in
the urine and its odor in the breath. Stadelmann believes that the con-
dition is not acetonsemia, but that the poisonous agent is an intermediate
product between the sugar and acetone, an oxy-butyric acid.
Saunders and Hamilton have described cases in which the lung capil-
laries were blocked with fat. They attributed the symptoms to fat embo-
lism, but there are many cases on record in which this condition was not
found, though lipasmia is by no means infrequent in diabetes.
The symptoms have been attributed to uraemia, and albuminuria fre-
quently precedes or accompanies the attack.
(2) Peripheral Neuritis. — The neuralgias., numbness, and tingling,
which are not uncommon symptoms in diabetes, are probably minor neu-
ritic manifestations.
Diabetic Tabes (so called). — This is a peripheral neuritis, characterized
by lightning pains in the legs, loss of knee-jerk — which may occur with-
out the other symptoms — and a loss of power in tlie extensors of the feet.
The gait is the characteristic steppage., as in arsenical, alcoholic, and other
302 CONSTITUTIONAL DISEASES.
forms of neuritic paralysis. Charcot states that there may be atrophy of
the optic nerves.
Diahctio Paraplegia. — This is also in all probability due to neuritis.
There are cases in wliich power has been lost in both arms and legs.
(3) Mental Syynptoms. — The patients are often morose, and there is a
strong tendency to become hypocliondriacal. General paralysis has been
known to develop.
(4) Special Senses. — Cataract is liable to occur, and may develop with
rapidity in young persons. Diabetic retinitis closely resembles the albu-
minuric form. Iltemorrhages are common. Sudden amaurosis, similar
to that which occurs in uraemia, may occur. Paralysis of the muscles of
accommodation may be present ; and lastly atrophy of the optic nerves.
Aural symptoms may come on with great rapidity, either an otitis media,
or in some instances inflammation of the mastoid cells.
(5) Sexual Function. — Impotence is common, and may be an early
symptom.
Course. — In children the disease is rapidly progressive, and may prove
fatal in a few days. It may be stated, as a general rule, that the older the
patient at the time of onset the slower the course. Cases without hered-
itary influences are the most favorable. In stout, elderly men diabetes
is a much more hopeful disease than it is in thin persons. Middle-aged
patients may live for many years, and persons are met with who have had
the disease for ten, twelve, or even fifteen years.
Diagnosis. — Glycosuria, which to all intents and purposes is a mild
form of the disease, is to be distinguished only by its transient character.
There is no other disease with which true diabetes can be confounded.
It must not be forgotten that hysterical women sometimes put sugar in
the urine for the purposes of deception.
Prognosis. — In true diabetes instances of cure are rare. On the
other hand, the transient or intermittent glycosuria, met with in stout
overfeeders, or in persons who have undergone a severe mental strain, is
very amenable to treatment. Xot a few of the cases of reputed cures be-
long to this division. Personally I have never seen recovery from a case of
true diabetes. Temporary arrest, reduction to a minimum of the amount
of sugar excreted, and prolonged periods of good health, I have frequently
seen, but neither in any one of my personal friends or acquaintances who
have suffered with the disease, nor in patients who have come under my
care in hospital or private practice, have I known permanent and com-
plete disappearance of the sugar, so that an ordinary diet could be taken
with impunity. Cures are, however, reported. Practically, in cases under
forty years of age the outlook is bad; in older persons the disease is less
serious and much more amenable to treatment.
Treatment. — In families with a marked predisposition to the disease
the use of slarcliy and saccharine articles of diet sliould be restricted.
Tlie personal hygiene of a diabetic patient is of the first importance.
DIABETES MELLITUS. 303
Sources of worry should bo avoided, and he should lead an even, quiot
life, if possible in an equable climate. Flannel or silk should be worn
next to the skin, and the greatest care should be taken to promote its
action. A lukewarm, or if tolerably robust, a cold bath, should be taken
every day. An occasional Turkish bath is useful. Systematic, moderate
exercise should be taken. When this is not feasible, massage should be
given.
Diet. — Our injunctions to-day are those of Sydenham : " Let the patient
eat food of easy digestion, such as veal, mutton, and the like, and abstain
from all sorts of fruit and garden stuff."
The carbohydrates in the food should be reduced to a minimum.
Under a strict hydrocarbonaceous and nitrogenous regimen all cases are
benefited and some are cured. The most minute and specific instructions
should be given in each case, and the dietary arranged with scrupulous
care. It is of the first importance to give the patient variety in the food,
otherwise the loathing of certain essential articles becomes intolerable, and
too often the patient gives up in disgust or despair. It is well, perhaps,
not to attempt the absolute exclusion of the carbohydrates, but to allow
a small proportion of ordinary bread, or, better still, as containing less
starch, potatoes. It is best gradually to enforce a rigid system, cutting off
one article after another. The following is a list of articles which diabetic
patients may take :
Liquids : Soups — ox-tail, turtle, bouillon, and other clear soups.
Lemonade, coffee, tea, chocolate, and cocoa ; these to be taken without
sugar, but they may be sweetened with saccharin. Potash or soda water,
and the Apollinaris, or the Saratoga Vichy, and milk in moderation, may
be used.
Of animal food : Fish of all sorts, salt and fresh, butcher's meat (with
the exception of liver), poultry, and game. Eggs, butter, buttermilk,
curds, and cream cheese.
Of bread : Gluten and bran bread, and almond and cocoanut biscuits.
Of vegetables : Lettuce, tomatoes, spinach, chiccory, sorrel, radishes,
water-cress, mustard and cress, cucumbers, celery, and endives. Pickles
of various sorts.
Fruits : Lemons, oranges, and currants. Nuts are, as a rule, allowable.
Among proliibited articles are the following : Thick soups, liver, crabs,
lobsters, and oysters; though, if the livers are cut out, oysters may be
used.
Ordinary bread of all sorts (in quantity): rye, wheaten, brown, or
white. All farinaceous preparations, such as hominy, rice, tapioca, semo-
lina, arrowroot, sago, and vermicelli.
Of vegetables : Potatoes, turnips, parsnips, squashes, vegetable marrow
of all kinds, beets, corn, artichokes, and asparagus.
Of liquids: I>eer, sparkling wine of all sorts, and the sweet aerated
drinks.
304 CONSTITUTIONAL DISEASES.
The chief difTiculty in arranging the daily meyiu of a diabetic patient
is the bread, and for it various substitutes have been advised — bran bread,
gluten bread, and almond biscuits. Most of these are unpalatable, and
the patients weary of them rapidly. Too many of them are gross frauds,
and contain a very much greater proportion of starch than represented.
A friend, a distinguished physician, who has, unfortunately, had to make
trial of a great many of them, writes : " That made from almond flour is
usually so heavy and indigestible that it can only be used to a limited ex-
tent. Gluten flour obtained in Paris or London contains about 15 per
cent of the ordinary amount of starch and can be well used. The gluten
flour obtained in this country has from 35 to 45 per cent of starch, and
can be used successfully in mild but not in severe forms of diabetes."
Unless a satisfactory and palatable gluten bread can be obtained, it is
better to allow the patient a few ounces of ordinary bread daily. The
" Soya " bread is not any better than that made from the best gluten flour.
As a substitute for sugar, saccharin is very useful, and is perfectly harm-
less. Glycerin may also be used for this purpose.
It is well to begin the treatment by cutting off article after article
until the sugar disaj^pears from the urine. Within a month or two the
patient may gradually be allowed a more liberal regimen. An exclusively
milk diet, either skimmed milk, buttermilk, or koumyss, has been recom-
mended by Donkin and others. Certain cases seem to improve on it, but
it is not, on the whole, to be recommended.
Medicinal Treatment, — This is most unsatisfactory, and no one drug
appears to have a directly curative influence. Opium alone stands the
test of experience as a remedy capable of limiting the progress of the dis-
ease. Diabetic patients seem to have a special tolerance for this drug.
Codeia is preferred by Pavy, and has the advantage of being less consti-
pating than morphia. A patient may begin with half a grain three times
a day, which may be gradually increased to six or eight grains in the
twenty-four hours. Mitchell Bruce, from a series of elaborate observa-
tions, concludes that morphia is decidedly more powerful. In a patient
at the University Hospital, Philadelphia, on whom I made a large number
of observations on the comparative value of these drugs, morphia ap-
peared to be much more potent. Patients take with benefit up to five or
six grains in the twenty-four hours. The expense, too, must sometimes
be taken into consideration : the cost of six grains of codeia daily would
be twenty-five cents, whereas the same amount of morphia would cost only
ten cents. Not much effect is noticed unless the patient is on a rigid
diet. When the sugar is reduced to a minimum, or is absent, the opium
should be gradually withdrawn. The patients not only bear well these
large doses of morphia, but they stand its gradual reduction. Potassium
bromide is often a useful adjunct. The arsenite of bromine, a solution of
arsenious acid with bromine in glycerin (dose, three to five minims after
meals), has been very highly recommended, but it is by no means so cer-
DIABETES INSIPIDUS. 305
tain as opium. Arsenic alone may be used. Antipyrin may be given in
doses of ten grains three times a day, and in cases witli a marked neurotic
constitution is sometimes satisfactory. I^he salicylates, iodoform, nitro-
glycerin, jambul, lithium salts, strychnine, creasote, and lactic acid have
been employed.
Of the complications, the jjruritis and eczema are best treated by cool-
ing lotions of boric acid or hyposulphite of soda ( 1 ounce ; water, 1
quart).
The coma is an almost hopeless complication. Inhalations of oxygen
have been recommended, and lately the intravenous injections of a saline
solution, as practised by Hilton Fagge. The three per cent solution of the
sodium bicarbonate has generally been employed. The treatment has not,
however, been satisfactory. Of seventeen cases, collected by Chadbourne,
in only one was it successful ; in seven there was temporary improvement ;
and the best that can be said for it is that it may give the patient a few
hours of complete consciousness. Injections should be made as soon as
possible after the appearance of the coma.
VIII. DIABETES INSIPIDUS.
Definition. — A chronic affection characterized by the passage of
large quantities of normal urine of low specific gravity.
The condition is to be distinguished from diuresis or polyuria, which
is a frequent symptom in hysteria, in Bright's disease, and occasionally
in cerebral or other affections. Willis, in 1674, first recognized the dis-
tinction between a saccharine and non-saccharine form of diabetes.
Etiology. — The disease is most common in young persons. Of the
85 cases collected by Strauss, 9 were under five years ; 12 between five and
ten years ; 36 between ten and twenty-five years. Males are more fre-
quently attacked than females. The affection may be congenital. A
hereditary tendency has been noted in many cases, the most extraordinary
of which has been reported by Weil. Of 91 members in four generations,
23 had persistent polyuria without any deterioration in health. Injury to
the nervous system has been present in certain instances, and the disease
has followed sunstroke, or a violent emotion, such as fright. Traumatism
has occasionally been the exciting cause. The injury may have been to
the head, but in other cases the lesion has been to the trunk or to the
limbs. The disease has followed rapidly the copious drinking of cold
water, or a drinking-bout; or has set in during the convalescence from an
acute disease. Tumors of the brain and lesions of the medulla have been
met with in a few instances. Cases of polyuria have been accompanied by
[laralysis of the sixth nerve. Maguire has seen an instance after menin-
gitis in which paralysis of the sixth pair occurred with it. Bernard, it
will be remembered, discovered a spot in the floor of the fourth ventricle
306 CONSTITUTIONAL DISEASES.
of animals which, when punctured, produced polyuria. Lesions of the
organs of the abdomen may be associated with an excessive flow of urine,
which, however, should not be regarded as true diabetes insipidus. Dick-
enson mentions its occurrence in abdominal tumors ; Ralfe, in abdominal
aneurism. I have noted it in several cases of tuberculous peritonitis.
The nature of the disease is unknown. It is, doubtless, of nervous
origin. The most reasonable view is that it results from a vaso-motor dis-
turbance of the renal vessels, due either to local irritation, as in a case of
abdominal tumor, or to central disturbance in cases of brain-lesion, or to
functional irritation of the centre in the medulla, giving rise to continu-
ous renal congestion.
Morbid Anatomy. — There are no constant anatomical lesions.
The kidneys have been found enlarged and congested. The Madder has
been found hypertrophied. Dilatation of the ureters and of the pelves of
the kidneys has been present. Death has not infrequently resulted from
chronic pulmonary disease. Very varied lesions have been met with in
the nervous system.
Symptoms. — The disease may come on rapidly, as after a fright or
an injury. More commonly it develops slowly. A copious secretion of
urine, with increased thirst, are the prominent features of the disease.
The amount of urine in the twenty-four hours may range from twenty to
forty pints, or even more. The specific gravity is low, 1-001 to 1*005 ; the
color is extremely pale and watery. The total solid constituents may not
be reduced. The amount of urea has sometimes been found in excess.
Abnormal ingredients are rare. Muscle sugar, inosite, has been occasionally
found. Albumen is rare. Traces of sugar have been met with. Naturally,
with the passage of such enormous quantities of urine, there is a propor-
tionate thirst, and the only inconvenience of the disease is the necessity
for frequent micturition and frequent drinking. The appetite is usually
good, rarely excessive as in diabetes mcllitus. The patients may be well
nourished and healthy-looking. The disease in many instances does not
appear to interfere in any way with the general health. The perspiration
is naturally slight and the skin is harsh. The amount of saliva is small
and the mouth usually dry. Cases have been described in which the toler-
ance of alcohol has been remarkable, and patients have been known to
take a couple of pints of brandy, or a dozen or more bottles of wine, in
the day.
The course of the disease depends entirely upon the nature of the pri-
mary trouble. Sometimes, with organic disease, either cerebral or abdomi-
nal, the general health is much impaired ; the patient becomes thin, and
ra]iidly loses strength. In the essential or idiopathic cases, good health
may be maintained for an indefinite period, and the affection has been
known to persist for fifty years. Death usually results from some inter-
current affection. Spontaneous cure may take place.
Diagnosis. — A low specific gravity c^nd the absence of sugar in the
IlICKETS. 307
urine distinguish the disease from diabetes mellitus. Hysterical polyuria
may sometimes simulate it very closely. The amount of urine excreted
may be enormous, and only the development of other hysterical manifes-
tations may enable the diagnosis to be made. This condition is, however,
always transitory.
In certain cases of chronic Bright's disease a very large amount of
urine of low specific gravity may be passed, but the presence of albumen
and of hyaline casts, and the existence of heightened arterial tension, stiff
vessels, and hypertrophied left ventricle make the diagnosis easy.
Treatment. — The treatment is not satisfactory. No attempt should
be made to reduce the amount of liquid. Opium is highly recommended,
but is of doubtful service. The preparations of valerian may be tried ;
either the powdered root, beginning with five grains three times a day, and
increasing until two drachms are taken in the day, or the valerianate of
zinc, in fifteen-grain doses, gradually increased to thirty grains, three times
a day. Ergot is recommended by DaCosta. Ergotin may be employed.
Large doses are required. Antipyrin, the salicylates, arsenic, strychnine,
turpentine, and the bromides have been recommended. The constant
current may be used — one pole on the loins, the other on the nape of the
neck.
IX. RICKETS.
Definition. — A disease of infants, characterized by impaired nutrition
and alterations in the growing bones.
Glisson, the anatomist of the liver, described the disease accurately in
the seventeenth century.
Etiology. — The disease exists in all parts of the world, but is par-
ticularly marked among the poor of the larger cities, who are badly housed
and ill fed. It is much more common in Europe than in America. In
the colored race it is frequently seen. It is a comparatively rare disease in
Canada. In the larger cities of this continent it is frequently seen at the
clinics, but in comparison with Vienna and London the contrast is very
striking. In these cities from 50 to 80 per cent of all the children at the
clinics present signs of rickets. Want of sunlight and impure air are im-
portant factors. A starchy diet, too much cows' milk, and the indiscrimi-
nate feeding, so common in the children of the poor, are important
agents; but something is required beyond these, for children of healthy
parents, who have an ample quantity of the proper food, may become
rickety. It seems probable, however, that the combination of defective
food and bad air plays the most important role. Prolonged lactation or
suckling a child during pregnancy are accessory etiological factors.
There is no evidence that the disease is hereditary, but there is prob-
ably a form of foetal rickets. It is doubtful, however, whether the changes
met with in this are identical with the post-natal disease. In these babies,
308 CONSTITUTIONAL DISEASES.
wliich are generally still-born, the limbs are short, the curves of the bones
are exaggerated, and at the junction of the epiphyses there is no prolifer-
ating zone of cartilage. This condition, which Parrot calls acliondroplasy^
is really more like a f(jotal cretinism.
Rickets affects male and female children equally. It is a disease of the
first and second years of life, rarely beginning before the sixth month.
Jenner has described a late rickets, in which form the disease may not ap-
pear until the ninth or even until the twelfth year. It has been held that
rickets is only a manifestation of congenital syphilis (Parrot), but this is
certainly not correct. Syphilitic bones rarely, if ever, present the spongy
tissue peculiar to rickets, and rachitic bones never show the multiple oste-
ophytes of syphilis. It has been regarded as an effect of malaria.
Morbid Anatomy. — The bones show the most important changes,
particularly the ends of the long bones and the ribs. Between the shaft
and epiphyses a slight bulging is apparent, and on section the zone of pro-
liferation, which normally is represented by two narrow hands, is greatly
thickened, bluish in color, more irregular in outline, and very much
softer. The width of this cushion of cartilage varies from five to fifteen
millimetres. The line of ossification is also irregular and more spongy
and vascular than normal. The periosteum strips off very readily from
the shaft, and beneath it there may be a spongioid tissue not unlike de-
calcified bone. The practical outcome of these changes is a delay in, and
imperfect performance of, the ossification, so that the bone has neither
the natural rate of growth nor the normal firmness. In the cranium
there may be large areas, particularly in the parieto-occipital region, in
which the ossification is delayed, producing the so-called cranio-tabes, so
that the bone yields readily to pressure with the finger. There are local-
ized depressed spots of atrophy, which, on pressure, give the so-called
" parchment crackling." Flat hyperostoses develop from the outer table,
particularly on the frontal and parietal bones, and produce the character-
istic broad forehead with prominent frontal eminences, a condition some-
times mistaken for hydrocephalus.
The chemical analysis of rickety bones shows a marked diminution in
the calcareous salts, which may be as low as from 25 to 35 per cent.
The liver and spleen are usually enlarged, and sometimes the mesen-
teric glands. As Gee suggests, these conditions probably result from the
general state of the health associated with rickets. It is interesting to
note that Beneke describes a relative increase in the size of the arteries in
rickets.
Kassowitz, who may be considered the leading authority on the anat-
omy of rickets, regards the hypernemia of the periosteum, the marrow, the
cartilage, and of tlie bone itself as the primary lesion, out of wliich all the
others develop. This disturbs the normal development of the growing
bone, and excites changes in the bone already formed. The cartilage cells
in consequence proliferate, the matrix is softer, and the bone which is
RICKETS. 309
formed from this unhealtliy cartiltigc is lacking in firmness and solidity.
In the bone already formed this excessive vascularity favors the normal
processes of absorption, so that the relation between removal and deposi-
tion is disturbed, absorption taking place more rapidly. The new material
is poor in lime salts. Kassowitz seems to have proved experimentally
that hypergemia of bone results in defective deposition of lime salts. Bar-
low and Bury * have given an elaborate analysis of the changes described
by this author. It is interesting to note that Glisson attributed rickets to
disturbed nutrition by arterial blood, and believed the changes in the long
bones to be due to excessive vascularity.
Symptoms. — The disease comes on insidiously about the period of
dentition, before the child begins to walk. In many cases digestive dis-
turbances precede the appearance of the characteristic lesions, and the
nutrition of the child is markedly impaired. There is usually slight
fever, the child is irritable and restless, and sleeps badly. If the child
has already walked, it shows a marked disinclination to do so, and seems
feeble and unsteady in its gait. Sir William Jenner has called attention
to three general symptoms which are present in many cases of rickets.
There is first a diffuse soreness of the body, so that the child cries when
an attempt is made to move it, and prefers to keep perfectly still. This
tenderness is often a marked and suggestive symptom. Associated with
this are slight fever and a tendency at night to throw off the bedclothes.
This may be partly due to the fact that the general sensitiveness is such
that even their weight may be distressing. And, third, there is such
profuse sweating, particularly about the head and neck, that in the morn-
ing the pillow is found soaked with perspiration.
The tissues become soft and flabby ; the skin is pale ; and from a
healthy, plump condition, the child becomes puny and feeble. It is in
this stage of the disease that we sometimes find such a degree of disability
in the muscles, particularly of the legs, that paralysis may be suspected.
This so-called pseudo-paresis of rickets results in part from the flabby,
weak condition of the legs and in part from the pain associated with the
movements. Such cases are by no means uncommon, but they are readily
distinguished from infantile paralysis. Coincident with, or following
closely upon, the general symptoms the characteristic skeletal lesions are
observed. Among the first of these to appear are the changes in the ribs,
at the junction of the bone with the cartilage, forming the so-called
rickety rosary. When the child is thin these nodules may be distinctly
seen, and in any case can be easily made out by touch. They very rarely
appear before the third month. They may increase in size up to the sec-
ond year, and are rarely seen after the fifth year. The thorax undergoes
important changes. Just outside the junction of the cartilages with the
ribs there is an ol>lique, shallow depression extending downward and out-
* Cyclopaedia of the Diseases of Cliildren, vol. ii.
310 CONSTITUTIONAL DISEASES.
ward. A transverse curve, sometimes called Harrison's groove, passes out-
ward from the level of the ensiform cartilage toward the axilla and may
be deepened at each inspiration. It is rendered more prominent by the
eversion and prominence of the costal border. The sternum projects,
particularly in its lower half, forming the so-called pigeon or chicken
breast. These changes in the thorax are not peculiar, however, to rickets,
and are much more commonly associated with hypertrophy of the tonsils,
or any trouble which interferes with the free entrance of air into the
lungs. Posteriorly the spine is usually curved, the processes are promi-
nent, and lateral curvature may be produced.
The head of a rickety child usually looks large, and the fontanelles
remain open for a long time. There are areas, particularly in the parieto-
occipital regions, in which ossification is imperfect ; and the bone may
yield to the pressure of the finger, a condition to which the term cranio-
tabes has been given. The relation of this condition to rickets is still
somewhat doubtful, as it is very often associated with syphilis — in 47 of
100 cases recently studied by George Carpenter. Coincidently with this,
hyperplasia proceeds in the frontal and parietal eminences, so that these
portions of the skull increase in thickness, and may form irregular bosses.
In one type the skull may be large and elongated, with the top considera-
bly flattened. In another, and perhaps more common case, the shape of
the skull, when seen from above, is rectangular — the caput quadratum.
The skull looks large in proportion to the face. The forehead is broad
and square, and the frontal eminences marked. The anterior fontanelle
is late in closing and may remain open until the third or fourth year.
The skin is thin, the veins are perceptible, and the hair is often rubbed
from the back of the skull. In contradistinction to the cranio-tabes is
the condition of cranio-sclerosis, which has also been ascribed to rickets.
On placing the ear over the anterior fontanelle, or in the temporal
region, a systolic murmur may frequently be heard. This condition, first
described by Fisher, of Boston, was believed by him to be peculiar to
rickets. While unquestionably heard with the greatest frequency in this
disease, its presence and persistence in perfectly healthy infants have been
amply demonstrated.* The murmur is rarely heard after the fifth year.
A knowledge of the existence of this systolic brain murmur may prevent
errors. A case in which it was well marked was reported as an instance
of supposed gummy tumor of the brain, in which the murmur was thought
to be due to pressure on the vessels at the base.
Changes occur in the bones of the face, chiefly in the maxillae, which
are reduced in size. The normal process of dentition is much disturbed ;
indeed, late teething is one of the marked features in rickets. The teeth
which appear may be small and badly formed.
* Oslcr, On tlic Systolic Brain Murmur of Children, Boston Medical and Surgical
Journal, 1880.
RICKETS. 311
In the upper limbs clianges in the scapuloB are not common. The
clavicle may be thickened at the sternal end, and there may be thickening
near the attachment of the sterno-cleido muscle. The most noticeable
changes are at the lower ends of the radius and ulna. The enlargement
is at the junction-area of the shaft and epiphysis. Less evident enlarge-
ments may occur at the lower end of the humerus. In severe cases the
natural shape of the bones of the arm may be much altered, having to
support the weight of the child in crawling on the floor. The changes in
the pelvis are of special importance, particularly in female children, as in
extreme cases they lead to great deformity and narrowing of the outlet.
In the legs, the lower end of the tibia first becomes enlarged ; and in
slight cases it may alone be affected. In the severe forms the upper end
of the bone, the corresponding parts of the fibula, and the lower end of
the femur become greatly thickened. If the child walks, slight bowing
of the tibiae inevitably results. In more advanced cases the tibiae and
even the femora may be arched forward. In ^ther cases the condition of
knock-knee occurs. Unquestionably the chief cause of these deformi-
ties is the weight of the body in walking, but muscular action takes
part in it. The green-stick fracture is not uncommon in the soft bones
of rickets.
These changes in the skeleton proceed slowly, and the general symp-
toms vary a good deal with their progress. The child becomes more or
less emaciated, though " fat rickets " is by no means uncommon. Fever
is not constant, but in actively progressing changes in the bone there is
usually a slight pyrexia. The abdomen is large, due partly to flatulent
distention, partly to enlargement of the liver, and in severe cases to
diminution of the volume of the thorax. The spleen is often enlarged and
readily palpable. The urine is stated to contain an excess of lime salts,
but Jacobi and Barlow say this has not been proved. No special or
peculiar changes, indeed, have as yet been described. Many rickety chil-
dren show marked nervous symptoms ; irritability, peevishness, and sleep-
lessness are constantly present. Jenner called attention to the close rela-
tionship which existed between rickets and infantile convulsions, par-
ticularly to the fits which occur after the sixth month. Tetany is by no
means uncommon. It involves most frequently the arms and hands ; oc-
casionally the legs as well. Laryngismus stridulus is a common complica-
tion, and though not, as some state, invariably associated with this disease,
yet it is certainly much more frequent in rickety than in other children.
Severe rickets interfere seriously with the growth of a child. Extreme
examples of rickety dwarfs are not uncommon. The disease known as
acute rickets is in reality a manifestation of scurvy and will be described
with that disease.
Prognosis. — The disease is never in itself fatal, but the condition
of the child is such that it is readily carried off by intercurrent affections,
particularly those of the respiratory organs. Spasm of the larynx and
21
312 CONSTITUTIONAL DISEASES.
convulsions occasionally cause death. In females the deformity of the
pelvis is serious, as it may lead to difficulties in parturition.
Treatment. — The better the condition of the mother during preg-
nancy the less likelihood is there of the development of rickets in the
child. Eapidly repeated pregnancies and suckling a child during preg-
nancy seem important factors in the production of the disease. Of the
general treatment, attention to the feeding of the child is the first con-
sideration. If the mother is unhealthy, or cannot from any cause nurse
the child, a suitable wet-nurse should be provided, or the child must be
artificially fed. Cows' milk, diluted according to the age of the child,
should constitute the chief food. Care should be taken to examine the
condition of the stools, and if curds are present the child is taking too
much, or it is not sufficiently diluted. Barley-water or carefully strained
and well-boiled oatmeal gruel form excellent additions to the milk.
The child should be warmly clad and should be in the fresh air and
sunshine the greater part of the day. It is a " vulgar error " to suppose that
delicate children cannot stand, when carefully wrapped up, an even low tem-
perature. The child should be bathed daily in warm water. Careful friction
with sweet oil is very advantageous, and, if properly performed, allays rather
than aggravates the sensitiveness. Special care should be taken to pre-
vent deformity. The child should not be allowed to walk, and for this
purpose splints applied so as to extend beyond the feet are very effective.
Of medicines, phosphorus has been warmly recommended by Kassowitz,
and its use is also advised by Jacobi. The child may be given gr. y^^
two or three times a day, dissolved in olive oil. Cod-liver oil, in doses
of from a half to one teaspoonf ul, is very advantageous. The syrup of the
iodide of iron may be given with the oil. The digestive disturbances,
together with the respiratory and nervous com2:)lications, should receive
appropriate treatment.
X. SCURVY (Scorbutus).
Definition. — A constitutional disease characterized by great debility,
with aiiajmia, a spongy condition of the gums, and a tendency to hagmor-
rhages.
Etiology. — The disease has been known from the earliest times, and
has prevailed particularly in armies in the field and among sailors on long
voyages.
From tlie early part of this century, owing largely to the efforts of
Lind and to a knowledge of the conditions upon which the disease de-
pends, scurvy has gradually disappeared from the naval service. In the
mercantile marine, cases still occasionally occur, owing to neglect of proper
and suitable food.
The disease develops whenever individuals have subsisted for pro-
SCURVY. 31'3
longed periods upon a diet in which fresh vegetables or their substitutes
are lacking.
In comparison with former times it is now a rare disease. In seaport
towns sailors suffering with the disease are occasionally admitted to hos-
pitals. In large almshouses, during the winter, cases are occasionally
seen.* On several occasions in Philadelphia characteristic examples were
admitted to my wards from the almshouse. Some years ago it was not
very uncommon among the lumbermen in the winter camps in the Ottawa
Valley. Among the Hungarian, Bohemian, and Italian min-^rs in Penn-
sylvania, cases of the disease are not infrequent. This so-called land
scurvy differs in no particular from the disease in sailors. An insufficient
diet appears to be an essential element in the disease, and all observers are
now unanimous that it is the absence of those ingredients in the food
which are supplied by fresh vegetables. What these constituents are has
not yet been definitely determined. Garrod holds that the defect is in the
absence of the potassic salts. Others believe that the essential factor is
the absence of the organic salts present in fruits and vegetables. Kalfe,
who has made a very careful study of the subject, believes that the absence
from the food of the malates, citrates, and lactates reduces the alkalinity
of the blood, which depends upon the carbonates directly derived from
these salts. This diminished alkalinity, gradually produced in the scurvy
patients, is, he believes, identical with the effect which can be artificially
produced in animals by feeding them with an excess of acid salts ; the
nutrition is impaired, there are ecchymoses, and profound alterations in
the characters of the blood. The acidity of the urine is greatly reduced
and the alkaline phosphates are diminished in amount.
In opposition to this chemical view it has been urged that the disease
really depends upon a specific micro-organism.
Other factors play an important part in the disease, particularly physi-
cal and moral influences ; overcrowding, dwelling in cold, damp quarters,
and prolonged fatigue under depressing influences, as during the retreat
of an army. Among prisoners, mental depression plays an important
role. It is stated that epidemics of the disease have broken out in the
French convict-ships en route to New Caledonia, even w^hen the diet was
amply sufficient. Nostalgia is sometimes an important element. It is an
interesting fact that prolonged starvation in itself does not necessarily
cause scurvy. Not one of the professional fasters of late years has dis-
played any scorbutic symptom. The disease attacks all ages, but the
old are more susceptible to it. Sex has no special influence, but during
the siege of Paris it was noted that the males attacked were greatly in
excess of the females. Infantile scurvy will be considered in a special
note.
Morbid Anatomy. — The anatomical changes are marked, though
* Henry, Philadelphia Hospital Reports, vol. i, 1890.
314: CONSTITUTIONAL DISEASES.
by no means specific, and are chiefly those associated with haemorrhage.
The blood is dark and fluid. There are no characteristic microscopical
alterations. The bacteriological examination has not yielded anything
very positive. Practically there are no changes in the blood, either ana-
tomical or chemical, which can be regarded as peculiar to the disease.
The skin shows the ecchymoses evident during life. There are haemor-
rhages into the muscles, and occasionally about or even into the joints.
Haemorrhages occur in the internal organs, particularly on the serous
membranes and in the kidneys and bladder. The gums are swollen and
sometimes ulcerated, so that in advanced cases the teeth are loose, and
have even fallen out. Ulcers are occasionally met with in the ileum and
colon. Haemorrhages are extremely common into the mucous membranes.
The spleen is enlarged and soft. Parenchymatous changes are constant
in the liver, kidneys, and heart.
Symptoms. — The disease is insidious in its onset. Early symptoms
are loss in weight, progressively developing weakness, and pallor. Very
soon the gums are noticed to be swollen and spongy, to bleed easily, and
in extreme cases to present a fungous appearance. The teeth may become
loose and even fall out. Actual necrosis of the jaw is not common. The
breath is excessively foul. The tongue is swollen, but may be red and
not much furred. The salivary glands are occasionally enlarged. The
lesions of the gums are rarely absent. The skin becomes dry and
rough, and ecchymoses soon appear, first on the legs and then on the
arms and trunk. They are petechial, but may become larger, and when
subcutaneous may cause distinct swellings. In severe cases, particularly
in the legs, there may be effusion between the periosteum and the bone,
forming irregular nodes, which, in the case of a sailor from a whaling
vessel, who came under my observation, had broken down and formed foul-
looking sores. The slightest bruise or injury causes haemorrhage into the
injured part. (Edema about the ankles is common. Haemorrhages from
the mucous membranes are less constant symptoms. Epistaxis is, however,
frequent. Haemoptysis and haematemesis are uncommon. Haematuria
and bleeding from the bowels may be present in very severe cases.
Palpitation of the heart and feebleness and irregularity of the impulse
are prominent symptoms. A haemic murmur can usually be heard at
the base. Hsemorrhagic infarction of the lungs and spleen has been de-
scribed. Respiratory symptoms are not common. The appetite is im-
paired, and owing to the soreness of the gums the patient is unable to
chew the food. Constipation is more frequent than diarrhoea. The urine
is often albuminous. The changes in the composition of the urine are
not constant; the specific gravity is high ; the color is deeper; and the
phosphates are increased. The statements with reference to the inorganic
constituents are contradictory. Some say the phosphates and potash are
deficient ; others that they are increased.
There are mental depression, indifference, in some cases headache, and
SCURVY. 315
in the latter stages delirium. Cases of convulsions, of hemiplegia, and of
meningeal haemorrhage have been described, llemarkable ocular symp-
toms are occasionally met with, such as night-blindness or day-blindness.
In advanced cases necrosis of the bones may occur, and in young
persons even separation of the epiphyses. There are instances in which
the cartilages have separated from the sternum. The callus of a recently
repaired fracture has been known to undergo destruction. Fever is not
present, except in the later stages, or when secondary inflammations in the
internal organs appear. The temperature may indeed be sometimes below
normal.
Scurvy in Children. — In infants and young children, fed upon improper
food, a form of cachexia develops which has been regarded as acute
rickets, but which Cheadle and Barlow have shown to be a form of scurvy.
The most striking cases develop in infants reared on artificial food pre-
pared with water, though the disease has occurred when these foods were
prepared with milk. Kickets strongly predispose to the condition. The
cases may occur in infants, or in children up to the age of ten. Barlow
thus summarizes the chief features :
" (1) Predominance of lower limb affection :
" (a) Immobility, going on to pseudo-paralysis ; (b) excessive tender-
ness ; (c) general swelling of lower limbs ; (d) skin shiny and tense, but
seldom pitting, and not characterized by undue local heat ; (e) on subsi-
dence, revealing a deep thickening of the shaft ; (/) liability to fracture
near the epiphyses.
" (2) Swelling of the gums, varying from definite sponginess down to
a vanishing-point of minute transient ecchymoses. These constitute the
chief diagnostic differentia between infantile scurvy and rickets, properly
so called. But to them must be added, as the most important diagnostic
of all, (3) definite and rapid amelioration by antiscorbutic regimen."
According to Gee, haematuria may be the only sign of scurvy in children.
Diagnosis. — No difficulty is met in the recognition of scurvy when
a number of persons are affected together. In isolated cases, however, the
disease is distinguished with difficulty from certain forms of purpura. The
association with manifest insufficiency in diet, and the rapid amelioration
with suitable food, are points by which the diagnosis can be readily
settled.
Prognosis. — The outlook is good, unless the disease is far advanced
and the conditions persist which lead to its development. The mortality
now is rarely great. During the civil war the death-rate was sixteen per
cent. Death results from gradual heart-failure, occasionally from sudden
syncope. Meningeal haemorrhage, extravasation into the serous cavities,
entero-colitis, and other intercurrent affections may prove fatal.
Prophylaxis. — The regulations of the Board of Trade require that a
sufficient supply of antiscorbutic articles of diet is taken on each ship; so
that now, except as the result of accident, the occurrence of scurvy on
316 CONSTITUTIONAL DISEASES.
board a vessel should lead to the indictment of the captain or owners for
criminal negligence. An outbreak of the disease in an almshouse is evi-
dence of culpable neglect on the part of the managers.
Treatment. — The juice of two or three lemons daily and a varied
diet, with j^lenty of fresh vegetables, suffice to cure all cases of scurvy,
unless far advanced. When the stomach is much disordered, small quan-
tities of scraped meat and milk should be given at short intervals, and the
lemon-juice in gradually increasing quantities. A bitter tonic, or a steel
and bark mixture, may be given. As the patient gains in strength, the
diet may be more liberal and he may eat freely of potatoes, cabbage,
water-cresses, and lettuce. The stomatitis is the symptom which causes
the greatest distress. The permanganate of potash or dilute carbolic acid
forms the best mouth-wash. Pencilling the swollen gums with a tolerably
strong solution of nitrate of silver is very useful. The solution is better
than the solid stick, as it reaches to the crevices between the granulations.
The constipation which is so common is best treated with large enemata.
For other conditions, such as haemorrhages and ulcerations, suitable
measures must be employed.
XI. PURPURA.
Strictly speaking this is a symptom, not a disease ; but under this
term are conveniently arranged a number of affections characterized by
extravasations of the blood into the skin. The purpuric spots vary from
one to three or four millimetres in diameter. When small and pin-point-
like they are called petechiae ; when large, they are known as ecchymoses.
At first bright red in color, they become darker, and gradually fade to
brownish stains. They do not disappear on pressure.
It is extremely difficult to make a satisfactory classification of purpura.
Perhaps as good a division as can be made is the following :
Symptomatic Purpura. — (a) Infectious. — In pyaemia, septicaemia,
malignant endocarditis (particularly in the latter affection), ecchymoses
may be very abundant. In typhus fever the rash is always purpuric.
Measles, scarlet fever, and more particularly small-pox, have each a variety
characterized by an extensive purpuric rash.
(b) Toxic. — The virus of snakes produces with great rapidity extrava-
sation of blood ; a condition which has been very carefully studied by
Weir Mitchell. Certain medicines, particularly copaiba, quinine, bella-
donna, mercury, ergot, and the iodides occasionally, are followed by a
petechial rash. Under this division, too, comes the purpura associated
with jaundice.
(c) Cachectic. — Under this heading are best described the instances of
purpura which develop in the constitutional disturbance of cancer, tuber-
culosis, Ilodgkin's disease, Bright's disease, scurvy, and in the debility of
PURPURA. 317
old age. In these cases the spots are usually confined to the extremities.
They may be very abundant in the lower limbs and about the wrists and
hands. This constitutes, probably, the commonest variety of tlie disease,
and many examples of it can be seen in the wards of any large hospital.
(d) Neurotic. — One variety is met with in cases of organic disease.
It is the so-called myelopathic purpura, which is seen occasionally in
locomotor ataxia, particularly following attacks of the lightning pains
and, as a rule, involving the area of the skin in which the pains have been
most intense. Cases have been met with also in acute myelitis and in
transverse myelitis, and occasionally in severe neuralgia. Another form
is the remarkable hysterical condition in which stigmata, or bleeding
points, appear upon the skin.
(e) Mechanical. — This variety is most frequently seen in venous stasis
of any form, as in the paroxysms of whooping-cough and in epilepsy.
Arthritic. — This form is characterized by involvement of the joints.
It is usually known, therefore, as rheumatic, though in reality the evi-
dence upon which this view is based is not conclusive. For the present
it seems more satisfactory to use the designation arthritic. Three groups
of cases may be recognized :
(a) A mild form, often known as Purpura simplex, seen most com-
monly in children, in whom, with or without articular pain, a crop of
purpuric spots appears upon the legs, less commonly upon the trunk and
arms. As pointed out by Graves, this form is not infrequently associated
with diarrhoea. The disease is seldom severe. There may be loss of ap-
petite, and slight anaemia. Fever is not, as a rule, present, and the pa-
tients get wxdl in a week or ten days. These cases are usually regarded
as rheumatic, and are certainly associated, in some instances, with un-
doubted rheumatic manifestations ; yet in a majority of the patients which
I have seen the arthritis was slighter than in the ordinary rheumatism of
children, and no other manifestations were present.
(b) Peliosis Rheumatica (Schonlein's Disease). — This remarkable affec-
tion is characterized by multiple arthritis, and an eruption which varies
greatly in characters, sometimes pui'ptii'ic, more commonly associated with
urticaria or with erythema exudativum. The disease is most common in
males between the ages of twenty and thirty. It not infrequently sets in
with sore throat, a fever from 101° to 103°, and articular pains. The
purpuric rash makes its appearance first on the legs or about the affected
joints. It may be a simple purpura or ordinary urticarial wheals. In
other instances there are nodular infiltrations, not to be distinguished
from erythema nodosum. The combination of wheals and purpura, the
purpura urticans^ is very distinctive. Much more rarely vesication is met
with, the so-called pempliigoid purpura. The amount of oedema is vari-
able ; occasionally it is excessive. In one case, which I saw in Montreal
with Molson, the chin and lower lip were enormously swollen, tense,
glazed, and deeply ecchymotic. The eyelids were swollen and purpuric.
318 CONSTITUTIONAL DISEASES.
while scattered over the cheeks and about the joints were numerous spots
of purpura urticans. These are the cases which have been described as
febrile p^irpuric cedema. The temperature range, in mild cases, is not
high, but may reach 102° or 103°.
The urine is sometimes reduced in amount and may be albuminous.
The joint affections are usually slight, though associated with much pain,
particularly as the rash comes out. Relapses may occur and the disease
may return at the same time for several years in succession.
The diagnosis of Schonlein's disease offers no difficulty. The associa-
tion of multiple arthritis with purpura and urticaria is very characteristic.
In a case which I saw with Musser there was endo-pericarditis, and the
question at first arose whether the patient had malignant endocarditis
with extensive cutaneous infarcts.
Schonlein's peliosis is thought by most writers to be of rheumatic
origin, and certainly many of the cases have the characters of ordinary
rheumatic fever, jylus purpura. By many, however, it is regarded as a
special affection, of which the arthritis is a manifestation analogous to
that which occurs in haemophilia. The frequency with which sore throat
precedes the attack, and the occasional occurrence of endocarditis or peri-
carditis, are certainly very suggestive of true rheumatism.
The cases usually do well, and a fatal event is extremely rare. The
throat symptoms may persist and give trouble. In two instances I have
seen necrosis and sloughing of a portion of the uvula.
(c) There is an arthritic purpura which presents marked gastro-in-
testinal and renal symptoms. This not uncommon but little recognized
form is met with most frequently in children and sets in usually with
pains, but rarely much swelling in the joints. Purpura or purpura urti-
cans develops about them, and the case at first looks like one of so-called
rheumatic purpura. Soon other symptoms develop : the child has attacks
of severe colic with vomiting and diarrhoea, true gastro-intestinal crises ;
which may recur with great frequency, particularly at night. There may
be haemorrhage from the bowels and soon renal symptoms. There are
albumen and tube-casts, often blood, and sometimes all the symptoms of
an intense haemorrhagic nephritis. The cases may drag on for months.
Death may occur from the nephritis, or from the severe gastro-intestinal
disturbance. Couty, who has given the best description of this affection,
regards it as a form of nervous purpura. This form has an interesting
connection with the angio-neurotic oedema, which is also characterized
by severe gastro-intestinal crises. Of four cases which have been under
my care one died of the nephritis.*
Purpura Heemorrliagica. — Under this heading may be consid-
ered the cases of very severe ])urpura with haemorrhages from the mucous
membranes. The affection, known as the morbus macidosus of Werlhof,
* New York Medical Journal, 1889.
PURPURA.
SVJ
is most commonly met with in young and delicate individuals, particu-
larly in girls ; but cases are described in which the disease has attacked
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Chart XIV. — Illustrates the rapidity with which anaemia is produced in purpura
hcEmorrhagica and the gradual recovery.
adults in full vigor. After a few days of weakness and debility, purpuric
spots appear on the skin and rapidly increase in numbers and size. Bleed-
ing from the mucous surfaces sets in, and the epistaxis, haematuria, and
haemoptysis may cause profound anagmia. Chart XIV illustrates the rapid-
ity with which anaemia is produced and the gradual recovery. Death may
take place from loss of blood, or from haemorrhage into the brain. Slight
fever usually accompanies the disease. In favorable cases the affection
terminates in from ten days to two weeks. There are instances of purpura
haemorrhagica of great malignancy, which may prove fatal within twenty-
four houra— purpura fidminans. This form is most commonly met with
in children, and is characterized by cutaneous haemorrhages, which develop
with great rapidity. Death may occur before any bleeding takes place
from the mucous membranes.
In the diagno.ns of purpura haemorrhagica it is important to exclude
scurvy, which may be done by the consideration of the previous health,
320 CONSTITUTIONAL DISEASES.
the circumstances under which the disease develops, and by the absence
of swelling of the gums. The malignant forms of the fevers, particularly
small-pox and measles, are distingished by the prodromata and the higher
tempeniture.
Treatment. — In symptomatic purpura attention should be paid to
the condilioiis under which it develops, and measures should be employed
to increase the strength and to restore a normal blood condition. Tonics,
good food, and fresh air meet these indications. In the simple purpura of
children, or that associated with slight articular trouble, arsenic in full
doses should be given. No good is obtained from the small doses, but the
Fowler's solution should be pushed freely until physiological effects are
obtained. In peliosis rheumatica the sodium salicylates may be given, but
with discretion. I confess not to have seen any special control of the haem-
orrhages by this remedy. We are still without a trustworthy medicine
which can always be relied upon to control purpura.
Aromatic sulphuric acid, ergot, turpentine, acetate of lead, or tannic
and gallic acids, may be used, and in some instances they seem to check
the bleeding. In other cases the whole series of haemostatics may be tried
in succession without any benefit.
XII. HAEMOPHILIA.
Definition. — An hereditary, constitutional fault, characterized by a
tendency to uncontrollable bleeding, either spontaneous or from slight
wounds. It is sometimes associated with a form of arthritis.
Early in the century several physicians of this country called attention
to the occurrence of profuse haemorrhage from slight causes. The fact
that fatal ha3morrhage might occur from slight, trifling wounds had been
known for centuries. The recognition of the family nature of the disease
is due to the writings of Buel, Otto, Hay, Coates, and others in this coun-
try. The disease has been elaborately treated in the monographs of Legg
and Grand id ier.
Etiology. — In a majority of cases the disposition is hereditary. The
fault may be acquired, however, but nothing is known of the conditions
under which the disease may thus arise in healthy stock.
The hereditary transmission in this disease is remarkable. In the
Appleton-Swain family, of Reading, Mass., there have been cases for
nejirly two centuries ; and F. F. Brown, of that town, tells me that in-
stances have already occurred in the seventh generation. The usual mode
of transmission is through the mother, who is not herself a bleeder, but
the daughter of one. Atavism through tlie female alone is almost the
rule, and tlie daugliters of a bleeder, though healthy and free from any
tendency, are almost certain to transmit the disposition to the male off-
spring. Tlie affection is much more common in males than in females,
HtEMOPIIILIA. 321
the proportion being estimated at eleven to one, or even thirteen to one.
The tendency usually appears within the first two years of life. It is rare
for manifestations to be delayed until the tenth or twelfth year. Families
in all conditions of life are affected. The bleeder families are usually
large. The members are healthy-looking, and usually have fine, soft skins.
Morbid Anatomy. — No special peculiarities have been described.
In some instances changes have been found in the smaller vessels ; but
in others careful studies have been negative. An unusual thinness of the
vessels has been noted. Haemorrhages have been found in and about the
capsules of the joints, and in a few instances inflammation of the synovial
surfaces. The nature of the disease is undetermined, and we do not yet
know whether it depends upon a peculiar frailty of the blood-vessels or
some peculiarity in the constitution of the blood, which prevents the nor-
mal thrombus formation in a wound.
Symptoms. — Usually haemophilia is not noted in the child until a
trifling cut is followed by serious or uncontrollable hemorrhage, or spon-
taneous bleeding occurs and presents insuperable difficulties in its arrest.
The symptoms may be grouped under three divisions : external bleedings,
spontaneous and traumatic ; interstitial bleedings, petechiae and ecchy-
moses; and the joint affections. The external bleedings may be spon-
taneous, but more commonly they follow cuts and wounds. In 334 cases
(Grandidier) the chief bleedings were epistaxis, 1G9 ; from the mouth, 43 ;
stomach, 15; bowels, 36; urethra, 16; lungs, 17; and in a few instances
bleeding from the skin of the head, the tongue, finger-tips, tear-papilla,
eyelids, external ear, vulva, navel, and scrotum.
Traumatic bleeding may result from blows, cuts, scratches, etc., and
the blood may be diffused into the tissues or discharged externally. Trivial
operations have proved fatal, such as the extraction of teeth, circumcision,
or venesection. It is possible that there may be local defects which make
bleeding from certain parts of the body more dangerous. D. Hayes Agnew
mentioned to me the case of a bleeder who had always bled from cuts and
bruises above the neck, never from those below. The bleeding is a capil-
lary oozing. It may last for hours, or even many days. Epistaxis may
prove fatal in twenty-four hours. In the slow bleeding from the mucous
surfaces large blood tumors may form and project from the nose or
mouth, forming remarkable-looking structures, and showing that the
blood has the power of coagulation. The interstitial haemorrhages may
be spontaneous, or may result from injury. Petechiae or large extravasa-
tions— hoematomata — may occur, the latter usually following blows.
The joint affections of haemophilia are remarkable. There may simply
be pain, or attacks which come on suddenly with fever, and closely resem-
ble acute rheumatism. The larger joints are usually affected. Arthritis
may usher in an attack of haemorrhage.
So far as the examination of the blood goes, no changes of special
moment have been noted. When the bleeding has been severe it is thin
322 CONSTITUTIONAL DISEASES.
and watery, but at the beginning of the bleeding the blood is rich in
corpuscles and coagulates firmly.
Diagnosis. — In the diagnosis of the condition the family tendency
is important. A single uncontrollable haemorrhage in child or adult is
not to be ranked as haemophilia ; but it is only when a person shows a
marked tendency to multiple haemorrhages, spontaneous or traumatic,
which tendency is not transitory but persists, particularly if there have
been joint affections, that we may consider the condition haemophilia.
Peliosis rheumatica is an affection which touches haemophilia very closely,
particularly in the relation of the joint swelling. It may also show itself
in several members of a family. The diagnosis from the various forms
of purpura is usually easy.
Prognosis. — The patients rarely die in tlie first bleeding. The
3^ounger the individual the worse is the outlook, though it is rarely fatal
in the first 3^ear. Grandidier states that of 152 boy subjects, 81 died before
the termination of the seventh year. The longer the bleeder survives the
greater the chance of his outliving the tendency ; but it may persist to
old age, as shown in the case of Oliver Appleton, the first reported Ameri-
can bleeder, who died at an advanced age of haemorrhage from a bed-sore
and from the urethra. The prognosis is graver in a boy than in a girl.
In the latter menstruation is sometimes early and excessive, but fortunate-
ly, in the female members of haemophilic families, neither this function
nor the act of parturition brings with it special dangers.
Treatment. — Members of a bleeder's family, particularly the boys,
should be guarded from injury, and operations of all sorts should be
avoided. Tlie daughters should not marry, as it is through them that the
tendency is propagated.
When an injury or wound has occurred, absolute rest and compression
should first be tried, and if these fail the styptics may be used. In epis-
taxis ice, tannin, and gallic acid maybe tried before resorting to plugging.
Internally ergot seems to have done good in several cases. Legg advises
the perchloride of iron in half-drachm doses every two hours with a
purge of sulphate of soda. Venesection has been tried in several cases.
Transfusion has been employed, but without success. During convales-
cence, iron and arsenic should be freely used.
SECTION III.
DISEASES OF THE DIGESTIVE SYSTEM.
I. DISEASES OF THE MOUTH.
STOMATITIS.
(1) Acute Stomatitis. — Simple or erythematous stomatitis, the com-
monest form of inflammation of the mouth, results from the action of
irritants of various sorts. It is frequent at all ages. In children it is
often associated with dentition and with gastro-intestinal disturbance,
particularly in ill-nourished, unhealthy subjects. In adults it follows the
overuse of tobacco and the use of too hot or too highly seasoned food. It
is a frequent concomitant of indigestion, and is met with in the acute spe-
cific fevers.
The affection may be limited to the gums and lips or may extend over
the whole surface of the mouth and include the tongue. There is at first
superficial redness and dryness of the membrane, followed by increased
secretion and swelling of the tongue, which is furred, and indented by the
teeth. There is rarely any constitutional disturbance, but in children
there may be slight elevation of temperature. The condition is sufficient
to cauee considerable discomfort, sometimes amounting to actual distress
and pain, particularly in mastication.
In infants the mouth should he carefully sponged after each feeding.
A mouth-wash of borax or the glycerine of borax may be used, and in se-
vere cases, which tend to become chronic, a dilute solution of nitrate of
silver (three or four grains to the ounce) may be applied.
(2) Aphthous Stomatitis. — This form, also known as follicular or ve-
sicidar stomatitis, is characterized by the presence of small, slightly raised
spots, from two to four millimetres in diameter, surrounded by reddened
areolae. The spots appear first as vesicles, which rupture, leaving small
ulcers with grayish bases and bright-red margins. They are seen most
frequently on the inner surfaces of the lips, the edges of the tongue, and
the cheeks. They are seldom present on the mucous membrane of the
pliarynx. Tliis form is met with most often in children under three years.
It may occur cither as an independent affection or in association with any
324 DISEASES OF THE DIGESTIVE SYSTEM.
one of the febrile diseases of childhood or with an attack of indigestion.
The crop of vesicles comes out with great rai^idity and the little ulcers
may be fully formed within twenty-four hours. The child complains of
soreness of the mouth and takes food with reluctance. The buccal secre-
tions are increased, and the breath is heavy, but not foul. The constitu-
tional symptoms are usually those of the disease with which the aphths3
are associated. The disease must not be confounded with thrush. No
special parasite has been found in connection with it. It is not a serious
condition, and heals rapidly with the improvement of the constitutional
state. In severe cases it may extend to the pillars of the fauces and to
the pharynx, and produce ulcers which are irritating and difhcult to
heal.
Each ulcer should be touched with nitrate of silver and the mouth
should be thoroughly cleansed after taking food. A wash of chlorate of
potash, or of borax and glycerine, may be used. The constitutional symp-
toms should receive careful attention.
(3) Ulcerative Stomatitis. — This form, which is also known by the
names of fetid stomatitis^ or putrid sore mouthy occurs particularly in
children after the first dentition. It may prevail as a wide-spread epi-
demic in institutions in which the sanitary conditions are defective. It
has been met with in jails and camps. Insufficient and unwholesome
food, improper ventilation, and prolonged damp, cold weather seem to
be special predisposing causes. Lack of cleanliness of the mouth, the
presence of carious teeth, and the collection of tartar around them favor
the development of the disease. The affection spreads like a specific dis-
ease, but the microbe has not yet been isolated. It has been held that
the disease is the same as the foot-and-mouth disease of cattle, and that
it is conveyed by the milk, but there is no positive evidence on these
points. Payne suggests that the virus is identical with that of conta-
gious impetigo.
The morbid process begins at the margin of the gums, which become
swollen and red, and bleed readily. Ulcers form, the bases of which are
covered with a grayish-white, firmly adherent membrane. In severe cases
the teeth may become loosened and necrosis of the alveolar process may
occur. The ulcers extend along the gum-line of the upper and lower
jaws ; the tongue, lips, and mucosa of the cheeks are usually swollen, but
rarely ulcerated. There is salivation, the breath is foul, and mastication
is painful. The submaxillary lymph glands are enlarged. The constitu-
tional symptoms are often severe, and in institutions death sometimes re-
sults in the case of debilitated children.
In the treatment of this form of stomatitis chlorate of potash has
been found to be almost specific. It should be given in doses of ten
grains, three times a day, to a child, and to an adult double that amount.
Locally it may be used as a mouth-wash, or the powdered salt may be ap-
plied directly to the ulcerated surfaces. AVhen there is much fetor a
STOMATITIS. 325
permaiiganatc-of -potash wash may ])c used, and an application of nitrate
of silver may l)e made to tlie ulcers.
There are several other varieties of ulcerative sore moutli, which differ
entirely from this form. Ulcers of the mouth are common in nursing
women, and are usually seen on the mucous membrane of the lips and
cheeks. They develop from the mucous follicles, and are from three to
five millimetres in diameter. They may cause little or no inconvenience ;
but in some instances they are very painful and interfere seriously with the
taking of food and its mastication. As a rule they heal readily after the
application of nitrate of silver, and the condition is an indication for
tonics, fresh air, and a better diet.
Parrot describes the occasional appearance in the new-born of small
ulcers symmetrically placed on the hard palate on either side of the mid-
dle line. They are met with in very debilitated children. The ulcers
rarely heal ; usually they tend to increase in size, and may involve the
bone.
(4) Parasitic Stomatitis (Thrush; Soor ; Muguet). — This affection,
most commonly seen in children, is dependent upon a fungus, the sac-
char omyces albicans^ called by Kobin the didium albicans. It belongs to
the order of yeast fungi, and consists of branching filaments, from the ends
of which ovoid torula cells develop. The disease does not arise appar-
ently in a normal mucosa. The use of an improper diet, uncleanliness of
the mouth, the acid fermentation of remnants of food, or the development,
from any cause, of catarrhal stomatitis predispose to the growth of the
fungus. In institutions it is frequently transmitted by unclean feeding-
bottles, spoons, etc. It is not confined to children, but is met with in
adults in the final stages of fever, in chronic tuberculosis, diabetes, and in
cachectic states. The parasite develops in the upper layers of the mucosa,
and the filaments form a dense felt-work among the epithelial cells. The
disease begins on the tongue and is seen in the form of slightly raised,
pearly-white spots, which increase in size and gradually coalesce. The
membrane thus formed can be readily scraped off, leaving an intact mu-
cosa, or, if the process extends deeply, a bleeding, slightly ulcerated sur-
face. The disease spreads to the cheeks, lips, and hard palate, and may
involve the tonsils and pharynx. In very severe cases the entire buccal
mucosa is covered by the grayish-white membrane. It may even extend
into the oesophagus and, according to Parrot, to the stomach and caecum.
It is occasionally met with on the vocal cords. Kobust, well-nourished
children are sometimes affected, but it is usually met with in enfeebled,
emaciated infants with digestive or intestinal troubles. In such cases the
disease may persist for months.
The affection is readily recognized, and must not be confounded with
aphthous stomatitis, in which the ulcers, preceded by the formation of
vesicles, are perfectly distinctive. In thrush the microscopical examina-
326 DISEASES OF THE DIGESTIVE SYSTEM.
tion sliows the presence of the characteristic fungus throughout the mem-
brane. In this condition, too, the mouth is usually dry — a striking contrast
to the salivation accompanying aphthae.
Thrush is more readily prevented tlian removed. The child's mouth
sliould be kept scrupulously clean, and, if artificially fed, the bottles
should be thoroughly sterilized. Lime-water or any other alkaline fluid,
such as the bicarbonate of soda (a drachm to a tumbler of water), may be
employed. When the patches are present these alkaline mouth-washes
may be continued after each feeding. A spray of borax or of sulphite
of soda (a drachm to the ounce) or the black wash with glycerine may
be employed. The permanganate of potassium is also useful. The con-
stitutional treatment is of equal imjoortance, and it will often be found
that the thrush persists, in spite of all local measures, until the general
health of the infant is improved by change of air or the relief of the diar-
rhoea, or, in obstinate cases, the substitution of a natural for the artificial
diet.
(5) Gangrenous Stomatitis [Cancrum Oris; Xo7na). — An affection
characterized by a rapidly progressing gangrene, starting on the gums or
cheeks, and leading to extensive sloughing and destruction. This terrible
but fortunately rare disease is seen only in children under very insanitary
conditions or during convalescence from the acute fevers. It is more
common in girls than in boys. It is met with between the ages of two
and five years. In at least one half of the cases the disease has developed
during convalescence from measles. Cases have been seen also after scar-
let fever and typhoid. The mucous membrane is first affected, usually of
the gums or of one cheek. It begins insidiously, and when first seen there
is a sloughing ulcer of the mucous membrane, which spreads rapidly and
leads to brawny induration of the skin and adjacent parts. The sloughing
extends, and in severe cases the cheek is perforated. The disease may spread
to the tongue and chin ; it may invade the bones of the jaws and even in-
volve the eyelids and ears. In mild cases an ulcer forms on the inner
surface of the cheek, which heals or may perforate and leave a fistulous
opening. Naturally in such a severe affection the constitutional disturb-
ance is very great, tlie pulse is rapid, the prostration extreme, and death
usually takes place within a week or ten days. The temperature may reach
103° or 104°. Diarrhooa is usually present, and aspiration pneumonia
often develops. II. R. AVharton has described a case in which there was
extensive colitis. Lingard has found in cases of noma a thread-like
bacillus, but its precise relation to the disease is doubtful. The highly
refractile bodies described by Sansom in the blood were probably blood-
plates.
Tlie treatment of the disease is unsatisfactory. In many cases the
onset is so insidious that there is an extensive sloughing sore when the case
first comes iTuder observation. Destruction of the sore by the cautery,
either the Paquelin or fuming nitric acid, is the most effectual. Antisep-
STOMATITIS. 327
tic applications should be made to destroy the fetor. The child should
be carefully nourished and stimulants given freely.
(6) Mercurial Stomatitis {Ptyalism). — An inflammation of the mouth
and salivary glands caused by mercury, which occurs chiefly in persons who
have a special susceptibility, and rarely now as a result of the excessive
use of the drug. It is met with also in persons whose occupation neces-
sitates the constant handling of mercury. It often follows the adminis-
tration of repeated small doses. Thus, a patient with heart disease who
was ordered an eighth of a grain of calomel every three hours for diu-
retic purposes had, after taking eight or ten doses, a severe stomatitis,
which persisted for several weeks. I have known it to follow also the admin-
istration of small doses of gray powder. The patient complains first of a
metallic taste in the mouth, the gums become swollen, red, and sore, mas-
tication is difficult, and soon there is a great increase in the secretion of
the saliva, which flows freely from the mouth. The tongue is swollen,
the breath has a foul odor, and, if the affection progresses, there may be
ulceration of the mucosa, and, in rare instances, necrosis of the jaw. Al-
though troublesome and distressing, the disease is rarely serious, and re-
covery usually takes place in a couple of weeks. Instances in which the
teeth become loosened or detached or in which the inflammation extends
to the phar\Tix and Eustachian tubes are rarely 'seen now.
The administration of mercury should be suspended so soon as the
gums are "touched." Mild cases of the affection subside within a few
days and require only a simple mouth-wash. In severer cases the chlorate
of potash may be given internally and used to rinse the mouth. The
bowels should be freely opened ; the patient should take a hot bath every
evening and should drink plentifully of alkaline mineral waters. Atropine
is sometimes serviceable, and may be given in doses of one one hundredth
of a grain twice a day. Iodine is also recommended. When the salivation
is severe and protracted the patient becomes much debilitated, anaemia de-
velops, and a supporting treatment is indicated. The diet is necessarily
liquid, for the patient finds the chief difficulty in taking food. If the pain
is severe a Dover powder may be given at night.
Here may be appropriately mentioned the influence of stomatitis, par-
ticularly the mercurial form, upon the developing teeth of children. The
condition known as erosion^ in which the teeth are honeycombed or
pitted owing to defective formation of enamel, is indicative as a rule of
infantile stomatitis. Such teeth must be distinguished carefully from
those of congenital syphilis, which may of course coexist, but the two
conditions are distinct. The honeycombing is frequently seen on the
incisors ; but, according to Jonathan Hutchinson, the test teeth of infan-
tile stomatitis are the first permanent molars, then the incisors, " which are
almost as constantly pitted, eroded, and of bad color, often showing the
transverse furrow which crosses all the teeth at the same level." Magitot
regards these transverse furrows as the result of infantile convulsions or
328 DISEASES OF THE DIGESTIVE SYSTEM.
of severe illnesses during early life. He thinks they are analogous to the
furrows on the nails which so often follow a serious disease.
II. DISEASES OF THE SALIYAEY GLANDS.
1. Hypersecretion {Ptyalism). — The normal amount of saliva varies
from two to three pints in the twenty-four hours. The secretion is in-
creased during the taking of food and in the physiological processes of
dentition. A great increase, to which the term ptyalism is applied, is met
with under many circumstances. It occurs occasionally in mental and
nervous affections and in rabies. Occasionally it is seen in the acute
fevers, particularly in small-pox. It has been met with during gestation,
usually early, though it may persist throughout the entire course. It has
been known to occur at each menstrual period ; and, lastly, it is a com-
mon effect of certain drugs. Mercury, gold, copper, the iodine com-
pounds, and (among vegetable remedies) jaborandi, muscarin, and tobacco
excite the salivary secretion. Of these we most frequently see the effect
of mercury in producing ptyalism. The salivation may be present with-
out any inflammation of the mouth.
2. Xerostomia {Arrest of the Salivary and Buccal Secretions ; Dry
Mouth). — In this condition, first described by Jonathan Hutchinson, the
secretions of the mouth and salivary glands are suppressed. The tongue
is red, sometimes cracked, and quite dry ; the mucous membrane of the
cheeks and of the palate is smooth, shining, and dry ; and mastication,
deglutition, and articulation are very difficult. The condition is not com-
mon. A majority of the cases are in women, and in several instances have
been associated with nervous phenomena. The general health, as a rule,
is unimpaired. Iladden suggests that it is due to involvement of some
centre which controls the secretion of the salivary and buccal glands. A
well-marked case came under my observation in a man aged thirty-two,
wlio was sent to me by Donald Baynes on account of a peculiar growth
along the gums. This proved to be the remnants of food which, owing to
the absence of any salivary or buccal secretions, collected along the gums,
became hardened, and adhered to them. The condition lasted for three
weeks, and was cured by the galvanic current.*
3. Inflammation of the Salivary Glands.
{a) Specific Parotitis. (See Mumps.)
(b) Symptomatic parotitis or parotid bubo occurs:
(1) In the course of the infectious fevers — typhus, typhoid, pneumo-
nia, pyaemia, etc. In ordinary practice it occurs of tenest, perhaps, in typhoid
fever. It is the result either of septic infection through the blood, or the in-
* Canada Medical and Surgical Journal, vol. v, p. 439, 1877.
DISEASES OF THE PHARYNX. 329
flammation, in many cases, passes up tlic salivary duct and so reaches the
gland. The process is usually very intense and leads rapidly to suppura-
tion. It is, as a rule, an unfavorable indication in the course of a fever.
(2) In connection with injury or disease of the abdomen or pelvis, a
condition to which Stephen Paget has called special attention. Of 101
cases of this kind, " 10 followed injury or disease of the urinary tract,
18 were due to injury or disease of the alimentary canal, and 23 were due
to injury or disease of the abdominal wall, the peritoneum, or the pelvic
cellular tissue. The remaining 50 were due to injury, disease, or tempo-
rary derangement of the genital organs." By temporary derangement is
meant slight injuries or natural processes — a slight blow on the testis, the
introduction of a pessary, menstruation, or pregnancy. He states that
this form of parotitis is not, as a rule, associated with signs of septicaemia
or pyaemia. It may occur in connection with gastric ulcer. Of the 101
cases 37 died, the majority of them not from the parotitis, but from the
primary lesion with which it was associated. After an operation it occurs
usually within the first week, often on the seventh day. There may be
pyrexia, but many cases are afebrile. One gland is usually attacked, but
both may be involved. In 78 cases in which the termination was noted
45 suppurated and 33 resolved without suppuration. The etiology of this
form of parotitis is obscure. Many of the cases are undoubtedly septic,
(3) In association with facial paralysis, as in a case of fatal peripheral
neuritis described by Gowers.
In the treatment of parotid bubo the application of half a dozen
leeches will sometimes reduce the inflammation and promote resolution.
When suppuration seems inevitable hot fomentations should be applied.
A free incision should be made early.
III. DISEASES OF THE PHARYNX.
(1) Circulatory Disturbances. — {a) Ilypermmia is a common condition
in acute and chronic affections of the throat, and is frequently seen as a
result of the irritation of tobacco smoke. Venous stasis is seen in valvular
disease of the heart, and in mechanical obstruction of the superior vena
cava by tumor or aneurism. In aortic insufficiency the capillary pulse
may sometimes be seen and the intense throbbing of the internal carotid
may be mistaken for aneurism.
{h) IIcBmorrhafje is found in association with bleeding from other
mucous surfaces, or it is due to local causes in the pharynx itself. In
the latter case it may be mistaken for haemorrhage from the lungs or
stomach. The bleeding may come from granulations or vegetations in
the naso-pharynx. Sometimes the patient finds the pillow stained in the
morning with bloody secretion. The condition is rarely serious, and only
22
380 DISEASES OF THE DIGESTIVE SYSTEM.
requires suitable local treatment of the pharynx. Occasionally a hiemor-
rhage takes place into the mucosa, producing a pharyngeal hagmatoma. I
have thrice seen a condition of the uvula resembling haemorrhagic infarc-
tion. One was in a patient with acute rheumatism, to whom large doses
of salicylic acid had been given ; the other two were instances of peliosis
rheumatica, in both of which partial sloughing of the uvula took place.
{c) (Edema. — An infiltrated a)dematous condition of the uvula and
adjacent parts is not very uncommon in conditions of debility, in pro-
found anaemia, and in Bright's disease. The uvula is sometimes from this
cause enormously enlarged, and may lead to difficulty in swallowing or in
breathing.
(2) Acute Pharyngitis {Sore Throat; Angina Simplex). — The entire
pharyngeal structures, often w4tli the tonsils, are involved. The condi-
tion may follow cold or exposure. In other instances it is associated with
constitutional states, such as rheumatism or gout, or with digestive dis-
orders. The patient complains of uneasiness and soreness in swallowing,
of a feeling of tickling and dryness in the throat, together with a con-
stant desire to hawk and cough. Frequently the inflammation extends
into the larynx and produces hoarseness. Not uncommonly it is only
part of a general naso-pharyngeal catarrh. The process may pass into
the Eustachian tubes and cause slight deafness. There is stiffness cf
the neck, the lymph glands of which may be enlarged and painful. Th3
constitutional symptoms are rarely severe. The disease sets in with a
chilly feeling and slight fever, and the pulse is increased in frequency.
Occasionally the febrile symptoms are more severe, particularly if the
tonsils are specially involved. The examination of the throat shows gen-
eral congestion of the mucous membrane, which is dry and glistening,
and in places covered with sticky secretion. The uvula may be much
swollen.
Acute pharyngitis lasts only a few days and requires mild measures.
If the tonsils are involved and the fever is high, aconite or sodium salicylate
may be given. Guaiacum also is beneficial ; but in a majority of the
cases a calomel purge or a saline aperient and inhalations with steam
meet the indications.
(3) Chronic Pharyngitis. — This may follow repeated acute attacks. It
is very conunon in i)crsons who smoke or drink to excess, and in those
who use the voice very much, such as clergymen, hucksters, and others.
It is frequently met with in chronic nasal catarrh. The naso-pharynx
and the posterior wall are the parts most frequently affected. The
mn(!ous niombrane is relaxed, the venules are dilated, and roundish
])()dies, from two to four millimetres in diameter, reddish in color, pro-
ject to a variable distance beyond the mucous membrane. These repre-
sent the proliferations of lymph tissue about the mucous glands. They
may be very abundant, forming elongated rows in the lateral walls
of the pharynx. AVith this there may be a dry glistening state of the
DISEASES OF THE PnARYNX. 331
pharyngeal mucosa, sometimes known as pharyngitis sicca. The pillars
of the fauces, and the uvula are often much relaxed. The secretion
forms at the batik of the pharynx and the patient may feel it drop down
from the vault, or it is tenacious and adherent, and is only removed by re-
peated efforts at hawking.
In the treatment^ special attention must be paid to the general health.
If possible, the cause should be ascertained. The condition is almost
constant in smokers, and cannot be cured without stopping the use of
tobacco. The use of food either too hot or too much spiced should be for-
bidden. When it depends upon excessive exercise of the voice, rest should
be enjoined. In many of these cases change of air and tonics help very
much. In the local treatment of the throat gargles, washes, and pastilles
of various sorts give temporary relief, but when the hypertrophic condi-
tion is marked the spots should be thoroughly destroyed by the galvano-
cautery. In many instances this affords great and permanent relief, but
in others the condition persists, and as it is not unbearable, the patient
gives up all hope of permanent relief.
(4) Ulceration of the Pharynx. — [a) Follicular. The ulcers are usu-
ally small, superficial, and generally associated with chronic catarrh.
(Z>) Syphilitic ulcers are usually painless, and most frequently situated
on the posterior wall of the pharynx. They occur in the secondary stage
as small, shallow excavations with the mucous patches. In the tertiary
stage the ulcers are due to erosion of gummata, and in healing they leave
whitish cicatrices.
(c) Tuberculous ulceration is not very uncommon in advanced cases
of phthisis, and, if extensive, is one of the most distressing features of the
later stages of the disease. The ulcers are irregular, with ill-defined edges
and grayish-yellow bases. The posterior wall of the pharynx may have an
eroded, worm-eaten appearance. These ulcers are, as a rule, intensely
painful.
(d) Ulcers occur in connection with pseudo-membranous inflamma-
tion, particularly the diphtheritic. In cancer and in lupus ulcers are also
present.
(e) Ulcers are met with in certain of the fevers, particularly in typhoid.
In many instances the diagnosis of the nature of pharyngeal ulcers is
very difficult. The tuberculous and cancerous varieties are readily recog-
nized, but it happens not infrequently that a doubt arises as to the
syphilitic character of an ulcer. In many instances the local condi-
tions may be uncertain. Then other evidences of syphilis should be
sought for, and the patient should be placed on mercury and iodide of
j)otassium, under which remedies syphilitic ulcers usually heal with great
rapidity.
(5) Acute Infectious Phlegmon of the Pharynx.— Under this term
Senator has described cases in which, along with dilliculty in swallowing,
soreness of the throat, and sometimes hoarseness, the neck enlarges, the
332 DISEASES OF THE DIGESTIVE SYSTEM.
pharyngeal mucosa becomes swollen and injected, the fever is high, the
constitutional symptoms are severe, and the inflammation passes on rap-
idly to suppuration. The symptoms are very intense. The swelling of the
pharyngeal tissues early reaches such a grade as to impede respiration.
Very similar symptoms may be produced by the lodgment of foreign
bodies in the phar3^nx.
(G) Retro -pharyngeal Abscess. — This may occur as a sequel to one of
the fevers, but more commonly results from caries of the cervical vertebrae.
It is accompanied with pain in swallowing, sometimes with cough, dysp-
noea, and alterations in the character of the voice.
The diagnosis is readily made, as the projecting tumor can be seen, and
felt with the finger on the posterior wall of the pharynx.
(7) Angina Ludovici {Ludwig's Angina ; Cellulitis of the Neck). — In
medical practice this is seen as a secondary inflammation in the specific
fevers, particularly diphtheria and scarlet fever. It may, however, occur
idiopathically or result from trauma. It is probably always a streptococ-
cus infection which spreads rapidly from the glands. The swelling at first
is most marked in the submaxillary region of one side. The symptoms
are, as a rule, intense, and, unless early and thorough surgical measures are
employed, there is great risk of systemic infection.
lY. DISEASES OF THE TOJS^SILS.
Apart from the affection of these glands already described in connec-
tion with diphtheria, scarlet fever, and syphilis, an acute and a chronic
tonsillitis may be recognized.
ACUTE TONSILLITIS.
(I) Follicular or Lacunar Tonsillitis. — For practical purposes, under
this name may be described the various forms which have been called ca-
tarrhal, erythematous, ulcero-membranous, and herpetic.
Etiology. — The disease is met with most frequently in young per-
sons, but in children under ten it is less common than the chronic form.
It is rare in infants. Sex has no special influence. Exposure to wet and
cold, and bad hygienic surroundings appear to have a direct etiological
connection with the disease. In so many instances defective drainage has
been found associated with outbreaks of follicular tonsillitis that sewer-gas
is regarded as a common exciting cause. One attack renders a patient
more lia))le to subsequent infection. Special stress is laid by some writers
upon tlie coexistence of tonsillitis with rheumatism. Cheadle describes it
as one of the phases of rheumatism in childhood with which articular at-
tacks may alternate. I cannot say that, in my experience, the connection
ACUTE TONSILLITIS. 333
between tlie two alTections lias been very striking, except in one point, viz.,
that an attack of acute rheumatism is not infrequently preceded by in-
flammation of the tonsils. The existence of pains in the limbs is no evi-
dence of the connection of the affection with rheumatism. A disease so
common and Avide-spread as acute tonsillitis necessarily attacks many per-
sons in whose families rheumatism prevails or who may themselves have
had acute attacks.
Mackenzie gives a table showing that in four successive years more
cases occurred in September than in any other month ; in October nearly
as many ; with July, August, and November next. In this country it seems
more prevalent in the spring. So many cases develop within a short time
that the disease may be almost epidemic. It spreads through a family in
such a way that it must be regarded as contagious.
An old notion prevails that there is a definite relation between the
tonsils and the testes and ovaries. F. J. Shepherd has called attention to
the circumstance that acute tonsillitis is a very common affection in newly
married persons. That view is probably correct which regards tonsillitis
as a local disease with severe constitutional manifestations, although the
fever is often high in proportion to the local symptoms. The commonest
organism found in tonsillitis is a streptococcus. Staphylococci also occur.
In some cases organisms closely resembling the bacillus diphthericB of
Loeffler have been found, but they do not seem to possess the same malig-
nancy.
Morbid Anatomy.— The lacunae of the tonsils become filled with
exudation products, which form cheesy-looking masses, projecting from
the orifices of the crypts. Not infrequently the exudations of contiguous
lacunas coalesce. The intervening mucosa is usually swollen, deep-red in
color, and may present herpetic vesicles or, in some instances, even mem-
branous exudation, in which case it may be difficult to distinguish the
condition from diphtheria. The creamy contents of the crypt are made
up of micrococci and epithelial debris.
Sjrmptoms.— Chilly feelings, or even a definite chill, and aching
pains in the back and limbs may precede the onset. The fever rises rap-
idly, and in the case of a young child may reach 105° on the evening of
the first day. The patient complains of soreness of the throat and diffi-
culty in swallowing. On examination, the tonsils are seen to be swollen
and the crypts present the characteristic creamy exudate. The tongue is
furred, the breath is heavy and foul, and the urine is highly colored and
loaded with urates. In children the respirations are usually very hurried,
and the pulse is greatly increased in rapidity. Swallowing is painful, and
the voice often becomes nasal. Slight swelling of the cervical glands is
present. In severe cases the symptoms increase and the tonsils become
still more swollen. The inflammation gradually subsides, and, as a rule,
within a week the fever departs and the local symptoms greatly improve.
The tonsils, however, remain somewhat swollen. The prostration and
334 DISEASES OP THE DIGESTIVE SYSTEM.
constitutional disturbance are often out of i)roportion to the intensity of
the local disease.
There are complications which occasionally excite uneasiness. Febrile
albuminuria is not uncommon, as Haig-Brown has pointed out. Cases of
endocarditis or pericarditis have been found. It is to be borne in mind
that in children an apex systolic murmur is by no means uncommon at
the height of any fever. The disease may extend to the middle ear.
The development of paralytic symptoms, local or general, after an attack
which has been regarded as follicular tonsillitis indicates an error in diag-
nosis.
Diagnosis. — It may be difficult to distinguish follicular tonsillitis
from diphtheria. It would seem, indeed, as if there were intermediate
forms between the mildest lacunar and the severer pseudo-membranous
tonsillitis. In the follicular form the individual yellowish-gray masses,
separated by the reddish tonsillar tissue, are very characteristic ; whereas
in diphtheria the membrane is of ashy gi*ay, and uniform, not patchy. A
point of the greatest importance in diphtheria is that the membrane is not
limited to the tonsils, but creeps up the pillars of the fauces or appears on
the uvula. The diphtheritic membrane when removed leaves a bleeding,
eroded surface ; whereas the exudation of lacunar tonsillitis is easily sepa-
rated, and there is no erosion beneath it. In all doubtful cases cultures
should, if possible, be made to determine the presence of Loeffler's bacillus.
(2) Suppurative Tonsillitis.
Etiology. — This arises under conditions very similar to those men-
tioned in the lacunar form. It may follow exposure to cold or wet, and is
particularly liable to recur. It is most common in adolescence. The in-
flammation is here more deeply seated. It involves the stroma, and tends
to go on to suppuration.
Symptoms. — The constitutional disturbance is very great. The
temperature rises to 104° or 105°, and the pulse ranges from 110 to 130.
Nocturnal delirium is not uncommon. The prostration may be extreme.
There is no local disease of similar extent which so rapidly exhausts the
strength of a patient. Soreness and dryness of the throat, with pain in
swallowing, are the symptoms of which the patient first complains. One
or both tonsils may be involved. They are enlarged, firm to the touch,
dusky red and oedematous, and the contiguous parts are also much swol-
len. The swelling of the glands may be so great that they meet in the
middle line, or one tonsil may even push the uvula aside and almost touch
the other gland. The salivary and buccal secretions are increased. The
glands of the neck enlarge, the lower jaw is fixed, and tlie patient is un-
able to open his mouth. In from two to four days the enlarged gland
becomes softer, and fluctuation can be distinctly felt by placing one finger
on the tonsil and the other at the angle of the jaw. The abscess usually
points toward the mouth, but it may point toward the pharynx. It may
burst spontaneously, affording instant and great relief. Suffocation has
CHRONIC TONSILLITIS. 335
followed the rupture of a large abscess and the entrance of the pus into the
larynx. When the suppuration is peritonsillar and extensive, the internal
carotid artery may bo opened ; but these are, fortunately, very rare accidents.
Treatment. — In the follicular form aconite may be given in full doses.
It acts very beneficially in children. The salicylates, given freely at the
outset, are regarded by some as specific, but I have seen no evidence of
such prompt and decisive action. At night, a full dose of Dover's pow-
der may be given. The use of guaiacum, in the form of two-grain loz-
enges, is warmly recommended. Iron and quinine should be reserved
until the fever has subsided. A pad of spongio-piline or thick flannel
dipped in ice-cold water may be applied around the neck and covered
with oiled silk. More convenient still is a small ice-bag. Locally the
tonsils may be treated with the dry sodium bicarbonate. The moistened
finger-tip is dipped into the soda, which is then rubbed gently on the
gland and repeated every hour. Astringent preparations, such as iron
and glycerine, alum, zinc, and nitrate of silver, may be tried. To cleanse
and disinfect the throat, solutions of borax or thymol in glycerine and
water may be used.
In suppurative tonsillitis hot applications in the form of poultices and
fomentations are more comfortable and better than the ice-bag. The
gland should be felt — it cannot always be seen — from time to time, and
should be opened when fluctuation is distinct. The progress of the dis-
ease may be shortened and the patient spared several days of great suffer-
ing if the gland is scarified early. The curved bistoury, guarded nearly
to the point with plaster or cotton, is the most satisfactory instrument.
The incision should be made from above downward, parallel with the an-
terior pillar. There are cases in which, before suppuration takes place,
the parenchymatous swelling is so great that the patient is threatened
with suffocation. In such instances the tonsil must either be excised or
tracheotomy or, possibly, intubation performed. Delavan refers to two
cases in which he states that tracheotomy would, under these circum-
stances, have saved life. Patients with this affection require a nourishing
liquid diet, and during convalescence iron in full doses.
CHRONIC TONSILLITIS.
{Chronic Naso-pharyngeal Obstruction ; Mouth- Breathing ; Aprosexia.)
Under this heading will be considered also hypertrophy of the adenoid
tissue in the vault of the j)harynx, sometimes known as the pharyngeal
tonsil, as the affection usually involves both the tonsils proper and this
tissue, and the symptoms are not to be differentiated.
Chronic enlargement of the tonsillar tissues is an affection of great im-
portance, and may influence in an extraordinary way the mental and bodily
development of children.
336 DISEASES OF THE DIGESTIVE SYSTEM.
Etiology. — Hypertrophy of the tonsillar structures is occasionally
congenital. Cases are perhaps most frequent in children, during the third
hemi-decade. The condition also occurs in young adults, more rarely in
the middle-aged. The enlargement may follow diphtheria or the eruptive
fevers. The frequency of the occurrence of adenoid growths in the naso-
pharynx has been variously stated. Meyer, to whom the profession is in-
debted for calling attention to the subject, found them in about one per
cent of the children in Copenhagen, while Chappell found sixty cases in
the examination of two thousand children in New York. These figures
give a very moderate estimate of the prevalence of the trouble. It occurs
equally in boys and girls, according to some WTiters with greater preva-
lence in the former.
Morbid Anatomy. — The tonsils proper present a condition of
chronic h3^pertrophy, due to multiplication of all the constituents of the
glands. The lymphoid elements may be chiefly involved without much
development of the stroma. In other instances the fibrous matrix is in-
creased, and the organ is then harder, smaller, firmer, and is cut with
much greater difficulty.
The adenoid grow^ths, which spring from the vault of the pharynx,
form masses varying in size from a small pea to an almond. They may
be sessile, with broad bases, or pedunculated. They are reddish in color,
of moderate firmness, and contain numerous blood-vessels. " Abundant,
as a rule, over the vault, on a line with the fossa of the Eustachian tube,
the growths may lie posterior to the fossa — namel}', in the depression
known as the fossa of Kosenmiiller, or upon the parts which are parallel
to the posterior wall of the pharynx. The growths appear to spring in
the main from the mucous membrane covering the localities where the
connective tissue fills in the inequalities of the base of the skull " (Har-
rison Allen). The growths are most frequently papillomatous with a
lymphoid parenchyma. Hypertrophy of the pharyngeal adenoid tissue
may be present without great enlargement of the tonsils proper. Chronic
catarrh of the nose usually coexists.
Symptoms. — The direct effect of chronic tonsillar hypertrophy is
the establishment of mouth-breathing. The indirect effects are deforma-
tion of the thorax, changes in the facial expression, and sometimes marked
alteration in the mental condition. The establishment of mouth-breath-
ing is the symptom which first attracts the attention. It is not so notice-
able by day, although the child may present the vacant expression charac-
teristic of this condition. At night the child's sleep is greatly disturbed ;
the respirations are loud and snorting, and there are sometimes prolonged
pauses, followed by deep, noisy inspirations. The child may wake up in a
paroxysm of shortness of breath. Some of these nocturnal attacks may be
due to reflex spasm of the glottis.
AVhcn the mouth-breathing has persisted for a long time definite
changes are brought about in the face, mouth, and chest. The facies is
CHRONIC TONSILLITIS. 337
so peculiar and distinctive that the condition may be evident at a glance.
The expression is dull, heavy, and apathetic, due in part to the fact that
the mouth is habitually left open. In long-standing cases the child is
very stupid-looking, responds slowly to questions, and may be sullen and
cross. The lips are thick, the nasal orilices small and pinched-in look-
ing, and in the mouth the superior dental arch is narrowed and the roof
considerably raised.
The remarkable alterations in the shape of the chest in connection with
enlarged tonsils were first studied by Dupuytren and J. Mason Warren.
They are liable to be mistaken for those of rickets. It is the commonest
cause of chest deformity in this country. " Anteriorly the ribs are promi-
nent, the sternum is angulated forward at the manubrio-gladiolar junction
and grooved at the gladiolo-xiphoid junction. A saucer-shaped depres-
sion is often found at the lower costal cartilages. The lower angle of the
scapula projects. While the ribs are separated far from each other ante-
riorly they are so closely pressed together posteriorly, especially at the
lower part of the chest, as to have the intercostal spaces practically oblit-
erated " (Harrison Allen). The prominent sternum (chicken breast)
with the circular depression in the lateral zones corresponding to the at-
tachment of the diaphragm are the most characteristic features. Dur-
ing sleep, in a chronic mouth-breather, with each inspiration the dia-
phragm may be seen to draw in the lower and lateral thoracic regions.
The voice is altered and acquires a nasal quality. The pronunciation
of certain letters is changed, and there is inability to pronounce the nasal
consonants n and m. Bloch, in his monograph,* lays great stress upon
the association of mouth-breathing with stuttering.
The hearing is impaired, usuady owing to the extension of inflamma-
tion along the Eustachian tube and its obstruction with mucus or the
narrowing of its orifice by pressure of the adenoid vegetations. In some
instances it may be due to retraction of the drums, as the upper pharynx
is insufficiently supplied with air. Naturally the senses of taste and smell
are much impaired. With these symptoms there may be little or no nasal
catarrh or discharge, but the pharyngeal secretion of mucus is always in-
creased. Children, however, do not notice this, as the mucus is usually
swallowed, but older persons expectorate it with difficulty.
Among other symptoms may be mentioned headache, which is by no
means uncommon, general listlessness, and an indisposition for physical
or mental exertion. Ilabit-spasm of the face has been described in con-
nection with it. I have known several instances in which permanent
relief has been afforded by the removal of the adenoid vegetations. Enu-
resis is occasionally an associatod symptom. The influence upon the men-
tal development is striking. Mouth-breathers are usually dull, stupid,
and backward. It is impossible for them to fix the attention for long at a
Die Pathologie und Therapie dcr Mundathmung. "Wiesbaden, 1889.
338 DISEASES OF THE DIGESTIVE SYSTEM.
time, and to this impairment of the mental function Guye, of Amsterdam,
has given the name aprosexia. Headaches, forgetfulness, inability to
study without discomfort, are frequent symptoms of this condition in stu-
dents. Tlie practitioner must bear in mind that all of these symptoms
may be found in connection with adenoid growths in the vault of the
pharynx without especial enlargement of the tonsils, and that both in
diagnosis and treatment particular attention must be paid to the former.
A symptom specially associated with enlarged tonsils is fetor of the
breath. In the tonsillar crypts the inspissated secretion undergoes de-
composition and an odor not unlike that of Rochef ort or Limburger cheese
is produced. The little cheesy masses may sometimes be squeezed from
the crypts of the tonsils. Though the odor may not apparently be very
strong, yet if the mass be squeezed between tlie fingers its intensity will at
once be appreciated. In some cases of chronic enlargement the cheesy
masses may be deep in the tonsillar cr\^ts ; and if they remain for a
prolonged period lime salts are deposited and a tonsillar calculus in this
way produced.
Children with enlarged tonsils are especially prone to take cold and to
recurring attacks of follicular disease. They are also more liable to diph-
theria, and in them the anginal features in scarlet fever are always more
serious.
Diagnosis. — Enlarged tonsils are readily seen on inspection of the
pharynx. There may be no great enlargement of the tonsils and nothing
apparent at the back of the throat even when the naso-pharynx is com-
pletely blocked with adenoid vegetations. In children the rhinoscopic
examination is rarely practicable. Digital examination is the most satis-
factory. The growths can then be felt either as small, flat bodies or, if
extensive, as velvety, grape-like papillomata.
Treatment. — If the tonsils are large and the general state is evi-
dently influenced by them they should be at once removed. Applications
of iodine and iron, or pencilling the crypts with nitrate of silver, are of
service in the milder grades, but it is waste of time to apply them in very
enlarged glands. There is a condition in which the tonsils are not much
enlarged, but the crypts are constantly filled with cheesy secretions and
cause a very bad odor in the breatli. In sucli instances the removal of
the secretion and tliorougli pencilling of the cr}'pts with chromic acid
may be practised. The galvano-cautery is of great service in many cases
of enlarged tonsils when there is any objection to the more radical surgi-
cal procedure.
Tlie treatment of the adenoid growths in the pliarynx is of the great-
est importance, and should be thoroughly carried out. Parents should
be frankly told that the affection is serious, one which impairs the men-
tal not less than the bodily development of the child. In spite of the
thorough ventilation of this subject by specialists, practitioners do not
appear to have grasped as yet the full importance of this disease. They
ACUTE CESOrilAGlTIS. 339
are far too apt to temporize and to postpone unnecessarily radical meas-
ures. The child must be etherized, wlien the growths can be removed
either with the finger-nail, wliicli in most instances is sufficient, or with
a suitable curette. Considerable lueinorrhage may follow, but it is usually
checked quickly. The good effects of the operation are often api)aront
within a few days, and the child begins to breathe through the nose. In
some instances the habit of mouth-breathing persists. As soon as the
child goes to sleep the lower Jaw drops and the air is drawn into the
mouth. In these cases a chin strap can be readily adjusted, which the
child may wear at night. In severe cases it may take months of careful
training befoi^e the child can speak properly.
Throughout the entire treatment attention should be paid to hygiene
and diet, and cod-liver oil and the iodide of iron may be administered
with benefit.
Y. DISEASES OF THE (ESOPHAGUS.
I. ACUTE CESOPHAGITIS.
Etiology. — Acute infiammation occurs (a) in the catarrhal processes
of the specific fevers ; more rarely as an extension from catarrh of the
pharynx, (b) As a result of intense mechanical or chemical irritation,
produced by foreign bodies, by very hot liquids, or by strong corrosives.
(c) In the form of pseudo-membranous inflammation in diphtheria, and
occasionally in pneumonia, typhoid fever, and pyaemia, (d) As a pustular
inflammation in small-pox, and, according to Laennec, as a result of a pro-
longed administration of tartar emetic, (e) In connection with local dis-
ease, particularly cancer either of the tube itself or extension to it from
without. And, lastly, acute oesophagitis, occasionally with ulceration, may
occur spontaneously in sucklings.
Morbid Anatomy. — It is extremely rare to see redness of the
mucosa, except when chemical irritants have been swallowed. More com-
monly the epithelium is thickened and has desquamated, so that the sur-
face is covered with a fine granular substance. The mucous follicles are
swollen and occasionally i?here may be seen small erosions. In the pseudo-
membranous inflammation there is a grayish croupous exudate, usually
limited in extent, at the upper portion of the gullet. This must not be
confounded witli the grayish-white deposit of thrush in children. The
pustular disease is very rare in small-pox. In the phlegmonous inflamma-
tion the mucous membrane is greatly swollen, and there is purulent infil-
tration in the submucosa. This may be limited as about a foreign body,
or extremely diffuse. It may even extend throughout a large part of the
gullet. Gangrene occasionally supervenes. Birch-IIirschfeld describes a
340 DISEASES OF THE DIGESTIVE SYSTEM.
remarkable case in an hysterical woman, who vomited a long membranous
tube which proved, on examination, to be the detached epithelial lining of
the oesophagus. Practically, in post-mortem work, there is no portion cf
the alimentary canal which more rarely shows signs of disease.
Symptoms. — Pain in deglutition is always present in severe inflam-
mation of the oesophagus, and in the form which follows the swallowing
of strong irritants may prevent the taking of food. A dull pain beneath
the sternum is also present. In the milder forms of catarrhal inflamma-
tion there are usually no symptoms. The presence of a foreign body is
indicated by dysphagia and spasm with the regurgitation of portions of
the food. Later, blood and pus may be ejected. It is surprising how ex-
tensive the disease may be in the oesophagus without producing much pain
or great discomfort, except in swallowing. The intense inflammation
which follows the swallowing of corrosives, when not fatal, gradually sub-
sides, and often leads to cicatricial contraction and stricture.
The treatment of acute inflammation of the oesophagus is extremely
unsatisfactory, particularly in the severer forms. The slight catarrhal
cases require no special treatment. When the dysphagia is intense it is
best not to give food by the mouth, but to feed entirely by enemata. Frag-
ments of ice may be given, and as the pain and distress subside, demulcent
drinks. External applications of cold often give relief.
A chronic form of oesophagitis is described, but it results usually from
the prolonged action of the causes which produce the acute form.
Associated with chronic heart disease and more frequently with the
senile and the cirrhotic liver, the oesophageal veins may be enormously
distended and varicose, particularly toward the stomach. In these cases
the mucous membrane is in a state of chronic catarrh, and the patient has
frequent eructations of mucus. Rupture of these oesophageal veins may
cause fatal haemorrhage. Two cases of the kind have occurred in my ex-
perience.
II. SPASM OF THE (ESOPHAGUS {(Esophagismus).
This so-called spasmodic stricture of the gullet is met with in hysteri-
cal patients and hypochondriacs, also in chorea, epilepsy, and especially
hydrophobia. It is sometimes associated also with the lodgment of
foreign bodies. The idiopathic form is found in females of a marked
neurotic habit, but may also occur in elderly men. It may be pres-
ent only during pregnancy. Of three cases which have come under my
observation, two were in men, one a hypochondriac over sixty years of
age who for many months had taken only liquid food, and with great
difficulty, owing to a spasm which accompanied every attempt to swallow.
The readiness with which the bougie passed and the subsequent history
showed the true nature of tlie case. The patient complains of inability to
STRICTURE OF THE (KSOPIIAGUS. 341
swallow solid food, and in extreme instances even liquids are rejected.
The attack may come on abruptly, and be associated with emotional dis-
turbances and with su})sternal pain. The bougie, when passed^ may be
arrested temporarily at the seat of the spasm, which gradually yields, or it
may slip through without the slightest effort. The condition is rarely seri-
ous. Death has however followed.
The diagnosis is not difficult, particularly in young persons with
marked nervous manifestations. In elderly persons oesophagismus is almost
always connected with hypochondriasis, but great care must be taken to
exclude cancer.
In some cases a cure is at once effected by the passage of a bougie.
The general neurotic condition also requires special attention.
Paralysis of the oesophagus scarcely demands separate consideration.
It is a very rare condition, due most often to central disease, particularly
bulbar paralysis. It may be peripheral in origin as in diphtheritic paraly-
sis. Occasionally it occurs also in hysteria. The essential symptom is
dysphagia.
III. STRICTURE OF THE CESOPHAGUS.
This results from : [a) Congenital narrowing, (h) The cicatricial con-
traction of healed ulcers, usually due to corrosive poisons, occasionally
to syphilis, {c) The growth of tumors in the walls, as in the so-called
cancerous stricture. Occasionally polypoid tumors projecting from the
mucosa produce great narrowing, {d) External pressure by aneurism, en-
larged lymph glands, enlarged thyroid, other tumors, and sometimes by
pericardial effusion.
The cicatricial stricture may occur anywhere in the gullet, and in ex-
treme cases may, indeed, involve the whole tube, but in a majority of in-
stances it is found either high up near the pharynx or low down toward
the stomach. The narrowing may be extreme, so that only small quanti-
ties of food can trickle through, or the obstruction may be quite slight.
There is usually no difficulty in making a diagnosis of the cicatricial strict-
ure, as the history of mechanical injury or the swallowing of a corrosive
fluid makes clear the nature of the case. When the stricture is low down
the oesophagus is dilated and the walls are usually much hyper trophied.
When it is high in the gullet the food is usually rejected at once, whereas
if low it may be retained and a considerable quantity collects before it is
regurgitated. Any doubt as to its having reached the stomach is removed
by the alkalinity of the materials ejected and the absence of the character-
istic gastric odor. Auscultation of the oesophagus may be practised and
is sometimes of service. The patient takes a mouthful of water and the
auHcultator listens along the left of the spine. During deglutition at the
seat of the stricture, in j)lace of the normal a.'sophageal bruit^ there will be
342 DISEASES OF THE DIGESTIVE SYSTEM.
lieard a loud splashing, gurgling sound. The passage of the oesophageal
bougie will determine more accurately the locality. Conical bougies at-
tached to a flexible whalebone stem are the most satisfactory, but the
gum-elastic stomach tube may be used ; a large one should be tried first.
The patient should be placed on a low chair with the head well thrown
back. The index finger of the left hand is passed far into the pharynx,
and in some instances this procedure alone may determine the presence of
a new growth. The bougie is passed beside the finger until it touches
the posterior wall of the phar}Tix, then along it, more to one side than in
the middle line, and so gradually pushed into the gullet. It is to be borne
in mind that in passing the cricoid cartilage there is often a slight ob-
struction. Great gentleness should be used, as it has happened more than
once that the bougie has been passed through a cancerous ulcer into the
mediastinum or through a diverticulum. I have known this accident to
happen twice — once in the case of a distinguished surgeon, who performed
cesophagotomy and passed the tube, as he thought, into the stomach. The
post-mortem on the next day showed that the tube had entered a diverticu-
lum and through it the left pleura, in which the milk injected through
the tube was found. In the other instance the tube passed through a
cancerous ulcer into the lung, which was adherent and inflamed jt For-
tunately these accidents, sometimes unavoidable, are extremely rare. It
is well always, as a precautionary measure before passing the bougie, to
examine carefully for aneurism, which may produce all the symptoms of
organic stricture. In cases in which the stricture is extreme there is al-
ways emaciation.
The prognosis in these cases is good so long as the stricture is dilatable.
The persistent treatment of cicatricial stricture by gradual dilatation is
very beneficial, and patients improve remarkably under this method.
AVhen extreme, the treatment by bougie is not possible, and the question
of cesophagotomy or gastrotomy must be considered. Rectal alimentation
should be employed whenever the patient is unable to take sufficient food
by the mouth.
IV. CANCER OF THE OESOPHAGUS.
This is usually epithelioma. It is not an uncommon disease, and oc-
curs more frequently in males than in females. The common situation is
in the upper third of the tube. At first confined to the mucous mem-
brane, tlic cancer gradually increases and soon ulcerates. The lumen of
tlie tube is narrowed, ])ut when ulceration is extensive in the later stages
the stricture may be less marked. Dilatation of the tube and hypertrophy
of the walls usually take place above the cancer. The cancerous ulcer
may perforate the trachea or a bronchus, the lung, the mediastinum, the
aorta or one of its larger branches, the pericardium, or it may erode the
RUPTURE OF THE O^SOPIIAGUS. 343
vertebral column. In my experience perforation of the lung has been the
most frequent, producing, as a rule, local gangrene.
Symptoms. — The earliest symptom is dysphagia, which is progress-
ive and may become extreme, so that the patient emaciates rapidly. Ke-
^ur<>-itation may take place at once ; or, if the cancer is situated near the
stomach, it may be deferred for ten or fifteen minutes, or even longer if
the tube is much dilated. The rejected materials may be mixed with
blood and may contain cancerous fragments. In persons over fifty years
of age persistent difficulty in swallowing accompanied by rapid emaciation
usually indicates oesophageal cancer. The cervical lymph glands are fre-
quently enlarged and may give early indication of the nature of the trouble.
Pain may be persistent or is present only when food is taken. In certain
instances the pain is very great. I saw an autopsy on a case of cancer of the
oesophagus in which the patient gradually became emaciated, but had no
special symptoms to call attention to the disease. These latent cases are,
however, very rare.
The prog7iosis is hopeless, and the patients usually become progressive-
ly emaciated, and die either of asthenia or sudden perforation of the ulcer.
In the diagnosis of the condition it is important, in the first place, to
exclude pressure from without, as by aneurism or other tumor. The
history enables us to exclude cicatricial stricture and foreign bodies. The
sound may be passed and the presence of the stricture determined. As
mentioned above, great care should be exercised.
Treatment. — In most cases milk and liquids can be swallowed, but
supplementary nourishment should be given by the rectum. It may be
advisable in some instances to pass a tube into the stomach and attempt
to feed in this way. If the patient is willing to take the risk, oesopha-
gotomy or gastrotomy may be performed in order to prolong life.
V. RUPTURE OF THE (ESOPHAGUS.
This may occur in a healthy organ as a result of prolonged vomiting.
Boerhaave described the first case in Baron Wassennar, who " broke asun-
der the tube of the oesophagus near the diaphragm, so that, after the
most excruciating pain, the elements which he swallowed passed, together
with the air, into the cavity of the thorax, and he expired in twenty-four
hours." Fitz has reported a case and has analyzed the literature on the
subject up to 1877. The accident has usually occurred during vomiting
after a full meal or when intoxicated. It is, of course, invariably fatal.
Much more common is the post-mortem digestion of the oesophagus,
which was first described by King, of Guy's Hospital. It is not very
infrequent. In one instance I found the contents of the stomach in the
left pleura. The erosion is in the posterior wall, and may be of consider-
able extent.
3-1:4: DISEASES OF THE DIGESTIVE SYSTEM.
VI. DILATATIONS AND DIVERTICULA.
Stenosis of tlie gullet is followed by secondary dilatation of the tube
above the constriction and great hypertrophy of the walls. Primary dila-
tation is extremely rare. The tube may attain extraordinary dimensions —
30 cm. in circumference in Luschka's case. Regurgitation of food is the
most common symptom. There may also be difficulty in breathing from
pressure.
Diverticula are of two forms : (a) Pressure diverticula, which are most
common at the junction of the pharynx and gullet, on the posterior wall.
Owing to weakness of the muscles at this spot, local bulging occurs, which
is gradually increased by the pressure of food, and finally forms a saccular
pouch. {!)) The traction diverticula situated on the anterior wall near
the bifurcation of the trachea, result, as a rule, from the extension of
inflammation from the lymph glands with adhesion and subsequent cica-
tricial contraction, by which the wall of the gullet is drawn out.
YI. DISEASES OF THE STOMACH.
I. METHODS OF CLINICAL EXAMINATION.
The stomach normally occupies the left upper quadrant of the abdo-
men, one quarter of the organ only lying to the right of the median
line; it is bordered above by the diaphragm and liver, below by the
intestine and transverse colon ; on the left it reaches the spleen, and on
the right it touches the gall-bladder; anteriorly it lies against the ribs
and the abdominal wall. The longitudinal axis extends from the left
above downward and backward to the right.
The cardiac orifice is about opposite the sternal border of the sixth or
seventh left costal cartilage. The highest point of the fundus reaches
the level of the fifth rib, or even that of the fourth interspace, while the
lowest point is 3 or 4 cm. above the navel. The pylorus lies on a level
with tlie tip of the xiphoid cartilage at a point midway between the right
sternal and parasternal lines ; it is normally covered by the left lobe of
the liver. With the stomach moderately filled wdth air the upper limit of
resonance reaches the fifth interspace in the left mammary line, while the
lower limit is several cm. above the navel.
The greatest vertical diameter of gastric resonance varies, according
to Paoanowski, from 10 to 14 cm. in the male, and is about 10 cm. in the
female.
Methods for determining the Position and Size of the Stomach. —
(1) Inflation by bicarbonate of soda and tartaric acid. Dissolve a tea-
spoonful of each separately in as small a quantity of water as possible,
METHODS OF CLINICAL EXAMINATION. 345
and let the patient drink tlio one solution immediately after the
other.
(2) Inflation by means of a bulb-syringe apparatus wliich can be at-
taclied to a stomacli tube already introduced.
(3) As a makeshift the patient may be given 250 to 500 c. c. of water
on an empty stomach in divided doses and the lower limit of the stomach
determined by percussion after each drink. The normal stomach sinks
gradually to a point a little above the navel, while the dilated and atonic
stomach falls rapidly to a much lower level.
The first method is the simplest and most practical, and is generally
one of the first steps in the physical examination ; the tube is not intro-
duced until the test-meal has been given. The method has the objection
that the amount of air introduced cannot be so well regulated and that
one may not in a given case fill the stomach to the entire capacity, while
occasionally a spasmodic contraction of the cardia and pylorus may give
the patient for a time some discomfort.
Auscultation of the Deglutatory Murmurs. — On listening at the tip
of the xiphoid cartilage as the patient swallows a mouthful of water one
hears normally two murmurs. (1) The primary murmur is heard syn-
chronously with the act of deglutition and sounds as if water were in-
jected into a space containing air. (2) The secondary murmur is heard
about twelve seconds later and is a coarser gurgling sound. It is well
while listening to place one hand on the trachea, as the first murmur may
be absent. In oesophageal and cardiac stenosis the second sound is de-
layed and altered in character.
The following description of methods is merely a rough summary.
For fuller particulars see the works of Ewald, Boas, Leo, AYesener, etc.
Examination of the Contents of the Stomach. — Various forms of test-
meals have been proposed. The simplest and most satisfactory is that
of Ewald. His test breakfast {Prohefrilhstilck) consists of one roll
(Brddchen) — about thirty grammes of white bread — and one glass of water
or a cup of tea without milk or sugar. One hour later the contents are
to be expressed.
The contents should not be more than 20 to 40 c. c. The filtrate
should be a clear yellow or yellowish-brown fluid. The fluid should con-
tain free hydrochloric acid ; it should not contain sufficient lactic acid to
be recognized by the ordinary tests. Pepsin and pepsinogen, the curdling
ferment and its zymogen, should be present.
Albuminoids should be almost entirely converted into peptones; pro-
peptones, if present at all, should be recognizable only in traces. Starches
should be so far converted into achroodextrin, dextrose, or maltose that
the reaction for starch or erythrodextrin with Lugol's solution should be
no longer present.
Chemical Examination of the Gastric Contents.
(1) Acidily may be determined by litmus papc^r.
23
34G DISEASES OF THE DIGESTIVE SYSTEM.
(2) Presence of Free Acid. — {a) Tropaeolin 0. 0. The brownish-
yellow color of the alcoholic solution is turned by the addition of a fluid
containing free acid to a deep mahogany brown or brown-red or deep
red, according to the strength of the acid. This is most commonly used
as tropa?olin paper — strips of filter paper soaked for some time in an alco-
holic solution. The paper must not be kept too long. It is best to make
up a new quantity monthly at least.
{h) Congo red. Solutions of Congo red of a brick-red color are turned
blue by the addition of a fluid containing pure acid. This is best used as
Congo paper, which is a very delicate reagent, and, on the whole, the most
satisfactory. Many other reagents have been used (methyl violet, fuch-
sin, malachite green, benzopurpurin), but the two above-mentioned tests
are probably as satisfactory as any.
(3) Presence of Free HCl. — The best and simplest test is that of Giinz-
burg : Phloroglucin, 2 ; vanillin, 1 ; absolute alcohol, 30. To a drop of
the gastric contents (better filtered) add a similar quantity of the reagent
on a porcelain plate. On evaporation gradually to dryness over a flame, a
beautiful rose-red color begins to appear at the edges if HCl is present.
This is merely a test for a free mineral acid, but HCl is the only one pres-
ent in the gastric juice.
(4) Presence of Lactic Acid. — The best test is that of Uffelmann.
Add 1 to 2 drops of tinctura ferri chloridi to 10 to 20 c. c. of a 5-per-
cent solution of carbolic acid and dilute with water till it assumes an
amethyst-blue color. On the addition of a few drops of a solution con-
taining lactic acid to about 1 c. c. of this solution the color changes to a
clear lemon-yellow. The test may be simulated in the presence of phos-
phates, mineral acids in concentration, grape sugar, alcohol, etc. ; hence
in cases of doubt it is always prudent to shake 20 c. c. of gastric juice with
10 c. c. of ether three times and then evaporate the ether to dryness over a
water bath. To the ether residue, which contains any lactic acid present,
add several drops of water. On the addition to this of an equal quantity
of the reagent a reliable test for lactic acid may be obtained.
(5) Butyric acid gives with Uffelmann's reagent a result very similar
to that with lactic acid. The color is, however, more brownish. The
odor is sufficient evidence of its presence for practical purposes, which is
also true of
(6) Acetic Acid.
Quantitative Tests. — {a) Test for the total acidity. This test is prac-
tically a test for the HCl, where this is present to any extent, as, under
these circumstances, other acids are present usually in unappreciable quan-
tities. To 5 to 10 c. c. of filtered gastric contents, a one-tenth normal
solution of sodic hydrate is added from a burette till neutralization. This
point can be determined by adding a drop of an alcoholic solution of phc-
nolphthaloin to the gastric juice. The solution remains colorless in acid or
neutral solution, but turns red in alkaline. This test estimates not only the
METHODS OF CLINICAL EXAMINATION. 347
free IICl, but that in combination. Normally 4 to G to G'5 of tlie one-tenth
solution is required. Each c. c. of this one-tenth solution = -003040 IICL
(b) Test for Free IICl. — If one desires to estimate more accurately the
free HCl, the simplest method is Boas's modification of that of Mintz.
From 10 c. c. of the gastric contents all organic acids are removed by
shaking with 100 c. c. of ether, and then the test performed as above until
Congo shows no longer a grayish-blue discoloration.
Quantitative tests for organic acids are complicated and in practice
unnecessary.
Tests for Pepsin and Curdling Ferment and their Zymogens. — In the
presence of free HCl it is unnecessary to examine for these elements, as
they may be safely assumed to be present.
(1) Test for Pepsin and Pepsinogen. — {a) In presence of HCl the
presence of pepsin may be determined by adding to 5 to 10 c. c. of the gas-
tric contents a small piece of Qgg albumen and observing digestion at 37°
to 40" during several hours.
(b) In the absence of HCl, pepsinogen alone is found. Add to 10 c. c.
of the filtered gastric contents 1 to 2 drops of a 25 per cent HCl solution ;
add, as before, a small shaving of Qgg albumen, and see if it is dissolved.
The HCl turns the pepsinogen into pepsin.
(2) Test for the Curdling Ferment and its Zymogen. — (a) Test for the
curdling ferment. Xeutralize exactly 5 to 10 c. c. of the filtered gastric
contents with one tenth normal NaOH solution and mix with an equal
quantity of neutral or amphoteric milk. If the ferment is present curd-
ling will occur in from ten to fifteen minutes at 37° to 40°. One may
proceed more simply by adding 3 to 5 drops of the filtered gastric juice
to 10 c. c. of milk, when curdling will occur as above.
{b) Test for the zymogen. To 10 c. c. of filtered gastric juice add
CaOJia till slightly alkaline. This sets the zymogen free, and, on mixing
with an equal quantity of milk, coagulation Avill occur as above.
These tests are of much value in the absence of HCl to determine the
condition of the mucous membrane. For HCl alone may be absent for a
greater or less length of time from various nervous causes, while the ab-
sence of pepsin and its curdling ferment at the same time Avould suggest a
serious impairment of the secretory functions.
Tests for the condition of the albuminoids in digestion are complicated,
and not necessary in an ordinary clinical examination (directions can be
found in the books of Ewald, Boas, Leo, von Jacksch, Wesener, etc.).
Tests for the Condition of the Starch. — If, after an hour of digestion,
the addition of a drop of Lugol's solution to the filtered gastric juice is
foHowed by the reaction for starch (blue) or erythrodextrin (purple), we
may know that the digestion of starch has been hindered. This is usually
due to a hyperacidity.
7'ests for the Motive Power of the Stomach. — Tliere are various meth-
ods, but i)ractical]y perfectly good results can be obtained by observation
348 DISEASES OF THE DIGESTIVE SYSTEM.
of tlie amount of fluid obtained after a test breakfast. More than 40 c. c.
is a sure indication of motor insufficiency. Large quantities are always
suggestive of dilatation.
Test for the Absorptive Power of the Stomach. — Kali iodidi (pure), 0-2
gramme, is taken in a perfectly clean capsule when the stomach is empty.
The sputa, tested every two or three minutes with starch and HNO3, give
the blue reaction inside of fifteen minutes in normal cases. The conclu-
sions to be drawn from this test are,' however, of little value.
II. ACUTE GASTRITIS
{Simple Gastritis; Acute Gastric Catarrh; Acute Drjspepsia).
Etiology. — Acute gastric catarrh, one of the most common of com-
plaints, occurs at all ages, and is usually traceable to errors in diet. It
may follow the ingestion of more food than the stomach can digest, or it
may result from taking unsuitable articles, which either themselves irritate
the mucosa or, remaining undigested, decompose, and so excite an acute
dyspepsia. A frequent cause is the taking of food which has begun to
decompose, particularly in hot weather. In children these fermentative
processes are very apt to excite acute catarrh of the bowels as well. An-
other very common cause is the abuse of alcohol, and the acute gastritis
which follows a drinking-bout is one of the most typical forms of the dis-
ease. The tendency to acute indigestion varies very much in different
individuals, and indeed in families. We recognize this in using the ex-
pressions a " delicate stomach '' and a " strong stomach." Gouty persons
are generally thought to be more disposed to acute dyspepsia than others.
Acute catarrh of the stomach occurs at the outset of many of the infec-
tious fevers.
Lebert described a special infectious form of gastric catarrh, occurring
in epidemic form, and only to be distinguished from mild typhoid fever by
the absence of rose spots and swelling of the spleen. Many practitioners
still adhere to the belief that there is a form of gastric fever., but the evi-
dence of its existence is by no means satisfactory, and certainly a great
majority of all cases in this country are examples of mild typhoid.
Morbid Anatomy. — Beaumont's study of St. Martin's stomach
showed tliat in acute catarrh the mucous membrane is reddened and
swollen, less gastric juice is secreted, and mucus covers the surface.
Slight haemorrhages may occur or even small erosions. The submucosa
may be somewhat cedematous. Microscopically the changes are chiefly
noticeable in the mucous and peptic cells, whicli are swollen and more
granular, and there is an infiltration of the intertubular tissue with leuco-
cytes.
Symptoms. — In mild cases the symptoms are those of slight " in-
digestion " — uncomfortable feeling in the abdomen, headache, depression,
ACUTE GASTRITIS. 349
nausea, eructations, and vomiting, which usually gives relief. The tongue
is heavily coated and the saliva is increased. In children, there are intes-
tinal symptoms — diarrhoea and colicky pains. The pulse may be slightly
increased, but in some instances is less frequent than normal ; there is
usually no fever. The duration is rarely more than twenty-four hours.
In the severer forms the attack may set in with a chill and febrile reac-
tion, in which the temperature rises to 102° or 103°. The tongue is
furred, the breath heavy, and vomiting is frequent. The ejected sub-
stances, at first mixed with food, subsequently contain much mucus and
bile-stained fluids. There may be constipation, but very often there is
diarrhoea. The urine presents the usual febrile characteristics, and there
is a heavy deposit of urates. The abdomen may be somewhat distended
and slightly tender in the epigastric region. Herpes may appear on the
lips. The attack may last from one to three days, and occasionally
longer. The examination of the vomitus shows, as a rule, absence of the
hydrochloric acid, presence of lactic and fatty acids, and marked increase
in the mucus.
Diagnosis. — The ordinary afebrile gastric catarrh is readily recog-
nized. The acute febrile form is so similar to the initial symptoms of
many of the infectious diseases that it is impossible for a day or two to
make a definite diagnosis, particularly in the cases which have come on,
so to speak, spontaneously and independently of an error in diet. Some
of these resemble closely an acute infection ; the symptoms may be very
intense, and if, as sometimes happens, the attack sets in with severe
headache and delirium the case may be mistaken for meningitis. When
the abdominal pains are intense the attack may be confounded with gall-
stone colic. In discriminating between acute febrile gastritis and the
abortive forms of typhoid fever it is to be borne in mind that in the
former the temperature rises abruptly, the remissions are slighter, and the
drop is more sudden. The initial bronchitis, the well-marked splenic
enlargement, and the rose spots are not present. It is a very common
error to class under gastric fever the mild forms of the various infectious
disorders.
Treatment. — Mild cases recover spontaneously in twenty-four hours,
and require no treatment other than a dose of castor oil in children or of
blue mass in adults. In the severer forms, if there is much distress in the
region of the stomach, the vomiting should be promoted by warm water
or the simple emetics. A full dose of calomel, eight to ten grains, should
be given, and followed the next morning by a dose of Hunyadi-Janos or
Carlsbad water. If there is eructation of acid fluid, bicarbonate of soda
and bismuth may be given. The stomach should have, if possible, abso-
lute rest, and it is a good plan in the case of strong persons, particularly
in those addicted to alcohol, to cut off all food for a day or two. The pa-
tient may be allowed soda water and ice freely. It is well not to attempt
to check the vomiting unless it is excessive and protracted. Recovery is
350 DISEASES OF THE DIGESTIVE SYSTEM.
usually complete, though repeated attacks may lead to subacute gastritis
or to the establishmeut of chronic dyspepsia.
Phlegmonous Gastritis ; Acute Suppurative Gastritis. — This is an ex-
cessively rare disease, characterized by the occurrence of suppurative pro-
cesses in the submucosa. The affection is more common in men than in
women. The cause is seldom obvious. It has been met with as an idio-
pathic affection, but it has occurred also in puerperal fever and other sep-
tic processes, and has occasionally followed trauma. Anatomically there
appear to be two forms, a diffuse purulent infiltration and a localized ab-
scess formation, in which case the tumor may reach the size of an egg, and
may burst into the stomach or into the peritoneal cavity.
The symptoms are variable. There are usually pain in the abdomen,
fever, dry tongue, and symptoms of a severe infective process, delirium
and coma preceding death. Jaundice has been met with in some in-
stances. Occasionally, when the abscess tumor is large, it has been felt
externally, in one case forming a mass as large as two fists. There are in-
stances which run a more chronic course, with pains in the abdomen,
fever, and chills.
The diagnosis is rarely possible, even when with abscess rupture oc-
curs, and the pus is vomited, as it is not possible to differentiate this con-
dition from an abscess perforating into the stomach from without. It is
stated, however, that Chvostek made the diagnosis in one of his cases.
Toxic Gastritis. — This most intense form of inflammation of the stom-
ach is excited by the swallowing of concentrated mineral acids or strong
alkalies, or by such poisons as phosphorus, corrosive sublimate, ammonia,
arsenic, etc. In the non-corrosive poisons, such as phosphorus, arsenic,
and antimony, the process consists of an acute degeneration of the gland-
ular elements, and haemorrhage. In the powerful concentrated poisons
the mucous membrane is extensively destroyed, and may be converted into
a brownish-black eschar. In the less severe grades there may be areas of
necrosis surrounded by inflammatory reaction, while the submucosa is
haemorrhagic and infiltrated. The process is of course more intense at
the fundus, but the active peristalsis may drive the poison through the
pylorus into the intestine.
The symptoms are intense pain in the mouth, throat, and stomach,
salivation, great difficulty in swallowing, and constant vomiting, the vom-
ited materials being bloody and sometimes containing portions of the
mucous membrane. The abdomen is tender, distended, and painful on
pressure. In the most acute cases symptoms of collapse supervene ; the
pulse is weak, the skin pale and covered with sweat ; there is restlessness,
and sometimes convulsions. There may be albumen or blood in the urine,
and pctcchiae may develop on the skin. When the poison is less intense,
tlie sloughs may separate, leaving ulcers, which too often lead, in the
oesophagus, to stricture, and in the stomach to chronic atrophy, and finally
to death from exhaustion.
CHRONIC GASTRITIS. 351
The diagnosis of toxic gastritis is usually easy, as inspection of the
mouth and pharynx shows, in many instances, corrosive eilects, wliile the
examination of the vomit may indicate the nature of the poison.
In poisoning by acids, magnesia should be administered in milk or
with agg albumen. When strong alkalies have been taken, tlie dilute acids
should be administered. For the severe inflammation which follows the
swallowing of the stronger poisons palliative treatment is alone available,
and morphia may be freely employed to allay the pain.
Diphtheritic or Membranous Gastritis. — This condition is met with
occasionally in diphtheria, but more commonly as a secondary process in
typhus or typhoid fever, pneumonia, pyaemia, small-pox, and occasionally
in debilitated children. An instance of it came under my notice in pneu-
monia. The exudation may be extensive and uniform or in patches.
The condition is not recognizable during life.
Mycotic and Parasitic Gastritis. — It occasionally happens that fungi
develop in the stomach and excite inflammation. One of the most re-
markable cases of the kind is that reported by Kundrat, in which the
favus fungus developed in the stomach and intestine.
In cancer and in dilatation of the stomach the sarcinae and yeast fungi
probably aid in maintaining the chronic gastritis. As a rule, the gastric
juice is capable of killing the ordinary bacteria. Orth states that the
anthrax bacilli, in certain cases, produce swelling of the mucosa and ulcer-
ation. Klebs has described a bacillus gasfricus which develops in the
tubules and produces numerous spores, and Eug. Fraenkel has reported a
case of acute emphysematous gastritis probably of mycotic origin. The
larvae of certain insects may excite gastritis, as in the cases reported by
Gerhard t, Meschede, and others. In rare instances tuberculosis and syphi-
lis attack the gastric mucosa.
Ill, CHRONIC GASTRITIS
{Chronic Catarrh of the Stomach; Chronic Dyspepsia).
Definition. — A condition of disturbed digestion associated with in-
creased mucus formation, qualitative or quantitative changes in the gastric
juice, enfeeblement of the muscular coats, so that the food is retained for
an abnormal time in the stomach ; and, finally, with alterations in the
structure of the mucosa.
Etiology. — The causes of chronic gastritis may be classified as fol-
lows : (1) Dietetic. The use of unsuitable or improperly prepared food.
The persistent use of certain articles of diet, such as very fat substances
or foods containing too much of the carbohydnites. The use in excess of
tea or coffee, and, above all, alcohol in its various forms. Under this head-
ing, too, may be mentioned the habits of eating at irregular hours or too
rapidly and imperfectly chewing the food. A common cause of chronic
352 DISEASES OF THE DIGESTIVE SYSTEM.
catarrh is drinking too freely of ice-water during meals, a practice which
plays no small part in the prevalence of dyspepsia in America. Another
frequent cause is the abuse of tobacco. (2) Constitutional causes. Ansemia,
chlorosis, chronic tuberculosis, gout, diabetes, and Bright's disease are
often associated with chronic gastric catarrh. (.3) Local conditions : (a) of
the stomach, as in cancer, ulcer and dilatation, which are invariably ac-
companied by catarrh ; (b) conditions of the portal circulation, causing
chronic engorgement of the mucous membrane, as in cirrhosis, chronic
heart disease, and certain chronic lung affections.
Morbid Anatomy. — Anatomically two forms of chronic gastritis
may be recognized, tlie simple and the sclerotic.
(a) Simple Chronic Gastritis.— -The organ is usually enlarged, the
mucous membrane pale gray in color, and covered with closely adherent,
tenacious mucus. The veins are large, patches of ecchymosis are not in-
frequently seen, and in the chronic catarrh of portal obstruction and of
chronic heart disease small haemorrhagic erosions. Toward the pylorus
the mucosa is not infrequently irregularly pigmented, and presents a
rough, wrinkled, mammillated surface, the etat mammelone of the French,
a condition which may sometimes be so prominent that writers have de-
scribed it as gastritis polyposa. The membrane may be thinner than
normal, and much firmer, tearing less readily with the finger-nail. Ewald
thus describes the histological changes : The minute anatomy shows the
picture of a parenchymatous and an interstitial inflammation. The gland
cells are in part eroded or show cloudy granular swelling or atrophy.
The distinction between the " haupt " and " beleg " cells cannot be recog-
nized, and in many places, particularly in the pyloric region, the tubes
have lost their regular form and show in many places an atypical branch-
ing, like the fingers of a glove. Individual glands are cut off toward the
fundus, but appear at the border of the submucosa as cysts, partly empty,
with a smooth membrane, partly filled with remnants of hyaline and re-
fractile epithelium. An abundant small-celled infiltration presses apart
the tubules and is particularly marked toward the surface of the mucosa,
and from the submucosa extensions of the connective tissue may be seen
passing between the glands. The mucoid transformation of the cells of
the tubules is a striking feature in the process and may extend to the very
fundus of the glands.
{b) Sclerotic Gastritis. — As a final result of the parenchymatous and
interstitial changes the mucous membrane may undergo complete atrophy,
so that but few traces of secreting substance remain. There appear to
be two forms of this sclerotic atrophy — one with thinning of the coats of
the stomach, /}Iithisis ventriculi^ and a retention or even increase of the
size of the organ ; the otlier with enormous thickening of the coats and
great reduction in the volume of the organ, the condition which is
usually described as cirrhosis vcntricuU. Extreme atrophy of the mu-
cous membrane of the stomach has been carefully studied by Fenwick,
CHRONIC GASTRITIS. 353
Ewald, and others, and wo now recognize the fact that there may be
such destruction and degeneration of the glandular elements by a pro-
gressive development of interstitial tissue that ultimately scarcely a trace
of secreting tissue remains. In a characteristic case, studied by Henry and
myself,* the greater portion of the lining membrane of the stomach was
converted into a perfectly smooth, cuticular structure, showing no trace
whatever of glandular elements, with enormous hypertrophy of the mus-
cularis mucosae, and here and there formation of cysts. In the other form,
with identical atrophy and cyst formation, there is enormous increase in
the connective tissue, and the stomach may be so contracted that it does
not hold more than a couple of ounces. The walls may measure from
two to three centimetres ; the greatest increase in thickness is in the sub-
mucosa, but the hypertrophy also extends to the muscular layers. While
one is not justified in saying that all cases of cirrhosis of the stomach rep-
resent a final stage in the history of a chronic catarrh, it is true that in
most cases the process is associated with atrophy of the gastric mucosa,
while the history indicates the existence of chronic dyspepsia.
Symptoms. — The affection persists for an indefinite period, and, as
is the case with most chronic diseases, changes from time to time. The
appetite is variable, sometimes greatly impaired, at others very good.
Among early symptoms are feelings of distress or oppression after eating,
which may become aggravated and amount to actual pain. When the
stomach is empty there may also be a painful feeling. The pain differs in
different cases, and may be trifling or of extreme severity. When local-
ized and felt beneath the sternum or in the prsecordial region it is known
as heart-burn or sometimes cardialgia. There is pain on pressure over
the stomach, usually diffuse and not severe. The tongue is coated, and
the patient complains of a bad taste in the mouth. The tip and margin
of the tongue are very often red. Associated with this catarrhal stomati-
tis there may be an increase in the salivary and pharyngeal secretions.
Nausea is an early symptom, and is particularly apt to occur in the morn-
ing hours. It is not, however, nearly so constant a symptom in chronic
gastritis as in cancer of the stomach, and in mild grades of the affec-
tion it may not occur at all. Eructation of gas, which may continue for
some hours after taking food, is a very prominent feature in cases of so-
called flatulent dyspepsia, and there may be marked distension of the
intestines. With the gas, bitter fluids may be brought up. In other in-
stances a clear watery fluid is ejected (pyrosis or water-brash). The vom-
iting does not often occur when the stomach is empty, but either imme-
diately after eating or an hour or two later. The vomitus consists of food
in various stages of digestion and slimy mucus, and the chemical examina-
tion shows the presence of abnormal acids, such as butyric, or even acetic, in
addition to lactic acid, while the hydrochloric acid, if indeed it is present,
* American Journal of the Medical Sciences, 188C.
35i DISEASES OF THE DIGESTIVE SYSTEM.
is much reduced in quantity. The digestion may be much delayed, and
on ^\ ashing out the stomach as late as seven hours after eating, portions
of food are still present. The prolonged retention favors decomposition,
the stomach becomes distended with gas, and this, with the chronic
catarrh, may induce gradually an atony of the muscular walls. The ab-
sorption is slow, and iodide of potassium, given in capsules, which should
normally reach the saliva within fifteen minutes, may not be evident for
more than lialf an hour.
Constipation is usually present, but in some instances there is diarrhoea,
and undigested food passes rapidly through the bowels. The urine is
often scanty, high-colored, and deposits a heavy sediment of urates.
Of other symptoms headache is common, and the patient feels con-
stantly out of sorts, indisposed for exertion, and low-spirited. In aggra-
vated cases melancholia may develop. Trousseau called attention to the
occurrence of vertigo, a marked feature in certain cases. The pulse is
small, sometimes slow, and there may be palpitation of the heart. Fever
does not occur. Cough is sometimes present, but the so-called stomach
cough of chronic dysj^eptics is in all probability dependent upon pharyn-
geal irritation.
The symptoms of atrophy of the mucous membrane of the stomach,
with or without contraction of the organ, are very complex, and cannot be
said to present a uniform picture. The majority of the cases present the
symptoms of an aggravated chronic dyspepsia, often of such severity that
cancer is suspected. In one of the cases which I examined the persistent
distress after eating, the vomiting, and thj gradual loss of flesh and
strength, very naturally led to this diagnosis, but the duration of the
disease far exceeded that of ordinary carcinoma. In the cirrhotic form
the tumor mass may sometimes be felt. In atrophy of the stomach,
whether associated with cirrhosis or not, the clinical picture may be that
of pernicious anaemia. As early as 1860, Flint called attention to this
connection between atrophy of the gastric tubules and anaemia, an obser-
vation which Fenwick and others have amply confirmed.
Diagnosis. — The use of the stomach-tube and the chemical examina-
tion of the contents of tlie stomach obtained in this way have given us
special information with reference to the various forms of gastritis and
the modes of differentiating them. Tlie soft-rubber stomach-tube, pro-
vided with a funnel-shaped dilatation, is the most satisfactory to use, as
it is very readily passed, and if used by the patient is not likely to cause
damage. It should be open at the end and possess one or two lateral
openings.
Ewald distinguishes three forms of chronic gastritis : (1) Simple gas-
tritis ; (2) mucous {schleimige) gastritis ; (3) atrophy.
In (1) the fasting stomach contains only a small quantity of a slimy
fluid, while after the test breakfast the HCl is diminished in quantity and
lactic acid and the fat acids are usually present.
CnHONIC GASTRITIS. 355
In (2) the acidity is always slight and the condition is distinguished
from (1) chiefly by the large amount of mucus present.
In (3) tlie fasting stomach is generally empty, while after the test
breakfast 11 01, pepsin, and the curdling ferment are wholly wanting.
Treatment. — When possible the cause in each case should be ascer-
tained and an attempt made to determine the special form of indi-
gestion. Usually there is no difficulty in differentiating the ordinary
catarrhal and the nervous varieties. A careful study of the phenomena
of digestion in the way already laid down, though not essential in
every instance, should certainly be carried out in the more obstinate and
obscure forms. Two important questions should be asked of every dys-
peptic— first, as to the time taken at his meals ; and, second, as to the
quantity he eats. Practically a large majority of all cases of disturbed
digestion come from hasty and imperfect mastication of the food and from
overeating. Especial stress should be laid upon the former point. In
some instances it will alone suffice to cure dyspepsia if the patient will
count a certain number before swallowing each mouthful. The second
point is of even greater importance. People habitually eat too much, and
it is probably true that a greater number of maladies arise from excess in
eating than from excess in drinking. Particularly is this the case in
America, where the average man is abstemious in the matter of alcohol,
but imprudent to a degree in all matters relating to food. Moreover, peo-
ple have not had time to learn the art of cooking, and much of the indi-
gestion, particularly in the country districts, may be charged to the bar-
barous methods of preparing the food. The treatment may be consid-
ered under the headings of dietetic and medicinal.
(a) General and Dietetic. — A careful and systematically arranged di-
etary is the first, sometimes the only essential in the treatment of a case of
chronic dyspepsia. It is impossible to lay down rules applicable to all
cases. Individuals differ extraordinarily in their capability of digesting
different articles of food, and there is much truth in the old adage, " One
man's food is another man's poison." The individual preferences for dif-
ferent articles of food should be permitted in the milder forms. Physi-
cians have probably been too arbitrary in this direction, and have not
yielded sufficiently to the intimations given by the appetite and desires
of the patient.
A rigid milk diet may be tried in obstinate cases. Much depends
upon whether the patient is able to take and digest milk properly. In the
forms associated with Bright's disease and chronic portal congestion, as
well as in many instances in which the dyspepsia is part of a neurasthenic
or hysterical trouble, this plan in conjunction with rest is most efficacious.
If milk is not digested well it may be diluted one third with soda water
or Vichy, or five to ten grains of carbonate of soda, or a pinch of salt
may be added to each tumblerful. In many cases the milk from whicli
the cream has been taken is better borne. Buttermilk is particularly
356 DISEASES OP THE DIGESTIVE SYSTEM.
suitable, but can rarely be taken for as long a time alone, as patients
tire of it much more readily than they do of ordinary milk. Not only
can the general nutrition be maintained on this diet, but patients some-
times increase in weight, and the unpleasant gastric symptoms disappear
entirely. It should be given at fixed hours and in definite quantities. A
patient may take six or eight ounces every three hours. The amount
necessary varies a good deal, but at least three to five pints should be
given in the twenty-four hours. This form of diet is not, as a rule, well
borne when there is a tendency to dilatation of the stomach. The milk
may be previously peptonized, but it is impossible to feed a chronic dys-
peptic in this way. The stools should be carefully watched, and if more
milk is taken than can be digested it is well to supplement the diet with
eggs and dry toast or biscuits.
In a large proportion of the cases of chronic indigestion it is not
necessary to annoy the patient with such strict dietaries. It may be quite
sufficient to cut off certain articles of food. Thus, if there are acid eruc-
tations or flatulency, the farinaceous foods should be restricted, particularly
potatoes and the coarser vegetables. A fruitful source of indigestion is
the hot bread which, in different forms, is regarded as an essential part
of an American breakfast. This, as well as the various forms of pan-
cakes, pies and tarts, with heavy pastry, and fried articles of all sorts,
should be strictly forbidden. As a rule, white bread, toasted, is more
readily digested than bread made from the whole meal. Persons, how-
ever, differ very much in this respect, and the Graham or brown bread is
for many people most digestible. Sugar and very sweet articles of food
should be taken in great moderation or avoided altogether by persons
with chronic dyspepsia. Many instances of aggravated indigestion have
come to my notice due to the prevalent practice of eating largely of ice-
cream. One of the most powerful enemies of the American stomach in
the present day is the soda-water fountain, which has usurped so impor-
tant a place in the apothecary shop.
Fats, with the exception of a moderate amount of good butter, very
fat meats, and thick, greasy soups should be avoided. Eipe fruit in
moderation is often advantageous, particularly when cooked. Bananas
are not, as a rule, well borne. Strawberries are to many persons a cause
of an annual attack of indigestion and sore throat in the spring months.
As stated, in the matter of special articles of food it is impossible to
lay down rigid rules, and it is the common experience that one patient
with indigestion will take with impunity the very articles which cause
the greatest distress to another.
Anotlier detail of importance which may be mentioned in this con-
nection is the general hygienic management of dyspeptics. These pa-
tients arc often introspective, dwelling in a morbid manner on their
symptoms, and much inclined to take a despondent view of their con-
dition. Very little progress can be made unless the physician gains
CHRONIC GASTRITIS. 357
tlicir confidence from the outset. Their fears and whims should not bo
made too light of or ridiculed. Systematic exercise, carefully regulated,
particularly when, as at watering places, it is combined with a restricted
diet, is of special service. Change of air and occupation, a prolonged
sea voyage, or a summer in the mountains will sometimes cure the most
obstinate dyspepsia.
(b) Medicinal. — The special therapeutic measures may be divided into
those which attempt to replace in the digestive juices important elements
which are lacking and those which stim.ulate the weakened action of the
organ. In the first group come the hydrochloric acid and ferments,
which are so freely employed in dyspepsia. The former is the most im-
portant. It is the ingredient in the gastric juice most commonly deficient.
It is not only necessary for its own important actions, but its presence is
intimately associated with that of the pepsin, as it is only in the presence
of a sufficient quantity that the pepsinogen is converted into the active
digestive ferment. It is best given as the dilute acid taken in somewhat
larger quantities than are usually advised. Ewald recommends large
doses — of from 90 to 100 drops — at intervals of fifteen minutes after the
meals. Leube and Eiegel advise smaller doses. Probably from 15 to 20
drops is sufficient. The prolonged use of it does not appear to be in
any way hurtful. The use, however, should be restricted to cases of
neurosis and atrophy of the mucous membrane. In actual gastritis its
value is doubtful.
The digestive ferments : These are extensively employed to strengthen
the weakened gastric and intestinal secretions. The use of pepsin, ac-
cording to Ewald, may be limited to the cases of advanced mucous
catarrh and the instances of atrophy of the stomach, in which it should
be given, in doses of from 10 to 15 grains, with dilute hydrochloric acid
a quarter of an hour after meals. It may be used in various different
forms, either as a powder or in solution or given with the acid. The
powder is much more certain. Pepsin wine is generally inert, as there is
little of the ferment taken up by alcohol. It is important to use a reliable
article. Much that is in the market is valueless.
Pancreatin is of equal or even greater value than the pepsin. Pains
should be taken to use a good article, such as that prepared by Merck. It
should be given in doses of from 15 to 20 grains, in combination with
bicarbonate of soda. It is conveniently administered in tablets, each
of which contains 5 grains of the pancreatin and the soda, and of these
two or three may be taken fifteen or twenty minutes after each meal.
Ptyalin and diastase are particularly indicated when the acid is excessive.
The action of the former continues in the stomach during normal diges-
tion. The malt diastase is often very serviceable given with alkalies.
Of measures which stimulate the glandular activity in chronic dys-
pepsia lavage is by far the most important, particularly in the forms
characterized by the secretion of a large quantity of mucus. Luke-warm
358 DISEASES OP THE DIGESTIVE SYSTEM.
water should be used, or, if there is much mucus, a one per cent salt solu-
tion, or a three to five per cent solution of bicarbonate of soda. If there
is much fermentation the three per cent solution of boric acid may be
used, or a dilute solution of carbolic acid. It is best employed in the
morning on an empty stomach, or in the evening some hours after the
last meal. It is perhaps preferable in the morning, except in those cases
in which there is much nocturnal distress and flatulency. Once a day is,
as a rule, sufficient, or, in the case of delicate persons, every second day.
The irrigation may be continued until the water Avhich comes away is
quite clear. It is not necessary to remove all the fluid after the irrigation.
AVhile perhaps in some hands this measure has been carried to ex-
tremes, it is one of such extraordinary value in certain cases that it should
be more widely employed by practitioners. When there is an insuperable
objection to lavage a substitute may be used in the form of warm alkaline
drinks, taken slowly in the early morning or the last thing at night.
Of medicines which stimulate the gastric secretion the most important
are the bitter tonics, such as quassia, gentian, columbo, cundurango, ipecacu-
anha, strychnia, and cardamoms. These are probably of more value in
chronic gastritis than the hydrochloric acid. Of these strychnia is the most
powerful, though none of them have probably any very great stimulating
action on the secretion, and influence rather the appetite than the digestion.
Of stomachics which are believed to favorably influence digestion the most
important are alcohol and common salt. The former would appear to act
in moderate quantities by increasing the acid in the gastric juice, and with
it probably the pepsin formation. Others hold that it is not so much the
secretory as the motor function of the stomach which the alcohol stimu-
lates. In moderate quantities it has certainly no directly injurious influ-
ence on the digestive processes. Special care should be taken, however, in
ordering alcohol to dyspeptics. If a patient has been in the habit of tak-
ing beer or light wines or stimulants with his meals, the practice may be
continued if moderate quantities are taken. Beer, as a rule, is not well
borne. A dry sherry or a glass of claret is preferable. In the case of
women with any form of dyspepsia stimulants should be employed with
the greatest caution, and the practitioner should know his patient w^ell
before ordering alcohol.
The importance of salt in gastric digestion rests upon the fact that its
presence is essential in the formation of the hydrochloric acid. An in-
crease in its use may be advised in all cases of chronic dyspepsia in which
the acid is dofoctive.
Treatment of Special Conditions. — Fermentation and flatu-
lency. AVlicn tlie digestion is slow or imperfect, fermentation goes on in
the contents, with the formation of gas and the production of lactic, bu-
tyric, and acetic acids. For the treatment of this condition careful diet-
ing may suffice, particularly forbidding such articles as tea, pastry, and
the coarser vegetables. It is usually combined with pyrosis, in which the
NEUROSES OF THE STOMACH. 359
acid fluids arc bronglit into the moiitli. Bismuth and carbonate of soda
sometimes suilice to relieve the coiulition. Thymol, creosote, and carbolic
acid may be employed. For acid dyspepsia Sir William Roberts recom-
mends the bismuth lozenge of the British PharmacopcL'ia, the antacid
properties of which depend on chalk and bicarbonate of soda. It should
be taken an hour or two after meals, and only when the pain and un-
easiness are present. Glycerine in from twenty to sixty minim doses, the
essential oils, animal charcoal alone or in combination with compound
cinnamon powder, may be tried. If there is much pain, chloroform in
twenty-minim doses or a teaspoonful of Hoffman's anodyne may be used.
If obstinate, lavage is indicated and is sometimes striking in its effects.
Alkaline solutions may be used.
Vomiting is not a feature which often calls for treatment in chronic
dyspepsia ; sometimes in children it is a persistent symptom. Creosote
and carbolic acid in drop doses, a few drops of chloroform or of dilute hy-
drocyanic acid, cocaine, bismuth, and oxalate of cerium may be used. If
obstinate, the stomach should be w^ashed out daily.
Constipation is a frequent and troublesome feature of most forms of
indigestion. Occasionally small doses of mercury, podophyllin, the laxa-
tive mineral waters, sulphur, and cascara may be employed. Glycerine sup-
positories or the injection of from half a teaspoonful to a teaspoonful of
glycerine is very efficacious.
Many cases of chronic dyspepsia are greatly benefited by the use of
mineral waters, particularly a residence at the springs with a careful super-
vision of the diet and systematic exercise. The strict regime of certain
Germ.an Spas is particularly advantageous in the cases in which the
chronic dyspepsia has resulted from excess in eating and in drinking.
Kissingen, Carlsbad, Ems, and Wiesbaden are to be specially recom-
mended.
IV. NEUROSES OF THE STOMACH.
(1) Gastralgla ; Gastrodynia. — Severe pains in the epigastrium, parox-
ysmal in character, occur [a) as a manifestation of a functional neurosis,
independent of organic disease, and usually associated with other nervous
symptoms (it is this form which will here be described) ; {h) in chronic
disease of the nervous system, forming the so-called gastric crises ; and
(c) in organic disease of the stomach, such as ulcer or cancer.
The functional neurosis occurs chiefly in women, very commonly in
connection with disturbed menstrual function or with pronounced hys-
terical symptoms. The affection may set in as early as puberty, but it is
more common at the menopause. Anaemic, constipated women who have
worries and anxieties at home are most prone to the affection. It is more
frequent in brunettes than in blondes. Attacks of it sometimes occur in
robust, healthy men. More often it is only one feature in a condition of
360 DISEASES OF THE DIGESTIVE SYSTEM.
general neurasthenia or a manifestation of that form of nervous dyspepsia
in which tlie gastric juice or hydrochloric acid is secreted in excess. I am
very skeptical as to the existence of a gastralgia of purely malarial origin.
The symptoms are very characteristic ; the patient is suddenly seized
with agonizing pains in the epigastrium, which pass toward the back and
around the lower ribs. The attack is usually- independent of the taking
of food, and may recur at definite intervals, a periodicity which has given
rise to the supposition in some cases that the affection is due to malaria.
The most marked periodicity, however, may be in the gastralgic attacks of
ulcer. They frequently come on at night. Vomiting is rare ; more com-
monly the taking of food relieves the pain. To this, however, there are
striking exceptions. Pressure upon the epigastrium commonly gives re-
lief, but deep pressure may be painful. It seems scarcely necessary to
separate the forms, as some have done, into irritative and depressive, as the
cases insensibly merge into each other. Stress has been laid upon the
occurrence of painful points, but they are so common in neurasthenia that
very little importance can be attributed to them.
The diagnosis offers many difficulties. Organic disease either of the
stomach or of the nervous system must be excluded. In the case of ulcer
or cancer this is not always easy. I well remember the case of a poor fel-
low who ^vas discharged from the Montreal General Hospital as a malin-
gerer. He had been a soldier, was well nourished, had no vomiting, but
had severe attacks of abdominal pain. The examination was negative, and
it was thought to be a case of simulation. A week subsequent to his dis-
charge he was readmitted with peritonitis from perforation. The fact
that the pain is most marked when the stomach is empty and is relieved
by the taking of food is sometimes regarded as pathognomonic of simple
gastralgia, but to this there are many exceptions, and in cancer the pains
may be relieved on eating. The prolonged intervals between the attacks
and their independence of diet are important features in simple gastralgia ;
but in many instances it is less the local than the general symptoms of the
case which enable us to make the diagnosis.
(2) Nervous Dyspepsia. — xVccording to Leube, who first separated it
from the ordinary gastric catarrh, nervous dyspepsia is characterized by
sensations of distress and uneasiness during digestion, and yet the act is
accomplished within the physiological time limit. The studies of Ewald,
Oser, Rosenbach, and others have greatly extended our knowledge of the
condition. The cases are met with most frequently in those who have
eitlier inlierited a neurotic constitution or have gradually, through indis-
cretions, brought about a condition of nervous prostration. All grades oc-
cur, from the emaciated, skeleton-like subject of anorexia nervosa to the
well-nourished, healthy-looking, fresh-complexioned patient whose con-
stant complaint is distress and uneasiness after eating. If in a case of
dyspepsia the stomach is found empty seven hours after tlie test dinner,
the supposition is that the trouble is nervous (Leube). The separation of
NEUROSES OF THE STOMACH. 361
the different forms can only be made accurately by the cliemical examina-
tion of the juices.
Clinical Forms. — Leu be recognizes three chief types, (a) Nervous
dyspepsia with normal secretion. There is no dilatation of the stomach,
no pain on pressure, and no change in the condition of the acid. The
test meal is digested within the normal time. Yet, despite the fact that
the motor and chemical functions of the organ are perfectly performed,
there are distress and uneasiness during the act of digestion. The patient
complains of pressure and distention of the stomach ; eructations occur.
(b) The condition of subacidity or inacidity. Lack of the normal
amount of acid is found in chronic catarrh, and particularly in cancer.
According to Leube, reduction in the normal amount of acid may exist
with the most pronounced symptoms of nervous dyspepsia, and yet the
stomach will be free from food within the regular time. A condition in
which the gastric juice is entirely without acid may occur in cancer, in ex-
treme sclerosis of the mucous membrane, and as a nervous manifestation
of hysteria, and occasionally of tabes. The most aggravated cases are
those associated with hysteria and neurasthenia. In addition to the gen-
eral symptoms, there are loss of appetite, sleeplessness, and gastric distress,
and when the stomach is empty there are uneasy local sensations and gen-
eral feelings of malaise, headache, and dizziness.
(c) Nervous dyspepsia with hyperacidity of the gastric juices. This is
a form of dyspepsia which has long been recognized, but of late has been
specially studied by Eeichman and others. The percentage of acid may
be doubled. This increase in the acid may be an intermittent condi-
tion or continuous. The periodic form is really a neurosis of secretion —
gastroxynsis of Rosenbach — which may be quite independent of the time
of digestion. Such cases are rare and are associated either with profound
neurasthenia or with locomotor ataxia. The attack may last for several
days. It usually sets in with a gnawing, unpleasant sensation of the
stomach, severe headache, and shortly after the patient vomits a clear,
watery secretion of such acidity that the throat is irritated and made
raw and sore. As mentioned, the attacks may be quite independent of
food. The chronic condition of hyperacidity is more common. Digestion
is usually retarded, particularly for the starches, and there are eructations
of acid fluid and gastric distress. There are instances also in which when
the stomach contains no food there is a secretion of a highly acid juice.
In these cases burning acid eructations, or even vomiting, occurring during
the night or early in the morning, are quite characteristic.
The relation of hyperacidity to gastric ulcer will be considered later.
(3) Nervous Vomiting ; Peristaltic Unrest ; Rumination.— («) Nerv-
ous Vomitinfj ■ — a condition which is not associated with anatomical
changes in the stomach or with any state of the contents, but is due to
nervous influences acting either directly or indirectly upon the centres
presiding over the act of vomiting. The patients are, as a rule, women —
24
362 DISEASES OF THE DIGESTIVE SYSTEM.
usually brunettes — and the subject of more or less marked hysterical mani-
festations. A special feature of this form is the absence of the prelimi-
nary nausea and of the straining efforts of the ordinary act of vomiting.
It is rather a regurgitation, and without visible effort and without gag-
ging the mouth is filled with the contents of the stomach, which are then
spat out. It comes on, as a rule, after eating, but may occur at irregular
intervals. In some cases the nutrition is not impaired, a feature which
may give a clew to the true nature of the disease, as there may be no other
hysterical manifestation present. As noted by Tuckwell, it may occur in
children. Kervous vomiting is rarely serious. Death may, however, fol-
low, as in the case reported by Garland,* in which a young woman, aged
twenty, had had from the age of two attacks of vomiting which lasted for
twenty-four hours, and which were very apt to occur when the cliild was
extra well and vivacious. She had St. Vitus's dance at eleven. At about
the age of twenty, she had excessive muscular twitchings, clonic in char-
acter and uncontrollable, and amounting to violent motion of the muscles.
When twenty-two she had severe headache, gradually lost flesh, and be-
came low-spirited. In January, 1884, she had headache, twitchings, and
constant vomiting, and died on the 13th. There was slight atrophy of
the mucous membrane of the stomach and slight increase in the firmness
of the kidneys.
A type of vomiting is that associated with certain diseases of the nerv-
ous system — particularly locomotor ataxia — forming part of the gastric
crises. Leyden has reported cases of primary periodic vomiting, which he
regards as a neurosis.
(b) Peristaltic Unr'est. — This condition, as described by Kussmaul, is
an extremely common and distressing symptom in neurasthenia. Shortly
after eating the peristaltic movements of the stomach are increased, and
borborygmi and gurgling may be heard, even at a distance. The sub-
jective sensations are most annoying, and it would appear as if in the
hyperaesthetic condition of the nervous system the patient felt normal
peristalsis, just as in these states the usual beating of the heart may
be perceptible to him. A further analogy is afforded by the fact that
emotion increases this peristalsis. It may extend to the intestines, par-
ticularly to the duodenum, and on palpation over this region the gur-
gling is most marked. The movement may be anti-peristalsis, in which
the wave passes from left to right, a condition which may also extend to
the intestines. There are cases on record in which colored enemata or
even scy])ala have been discharged from the mouth.
(c) Rumination ; Merycism^is. — In this remarkable and rare condi-
tion tlie patients regurgitate and chew the cud like ruminants. It occurs
in neurasthenic or hysterical persons, epileptics, and idiots. In some in-
stances it is hereditary. There is an instance in which a governess taught
* Transactions of the Association of American Physicians, vol. iv.
NEUROSES OF THE STOMACH. 3G3
it to two children. The habit may persist for years, and does not neces-
sarily impair the health.
Treatment of Neuroses of the Stomach. — The gastralgia, if
very severe, requires morpliia, which is best administered subcutaneously
in combination with atropia. In the milder attacks the combination of
morphia (gr. -J) with cocaine and belladonna is recommended, by Ewald.
The greatest caution should, however, be exercised in these cases in the
use of the hypodermic syringe. It is preferable, if opium is necessary, to
give it by the mouth, and not to let the patient know the character of the
drug. Chloroform, in from ten to twenty drop doses, or Hoffman's ano-
dyne will sometimes allay the severe pains. The general condition should
receive careful attention, and in many cases the attacks recur until the
health is restored by change of air with the prolonged use of arsenic. If
there is anaemia iron may be given freely. Nitrate of silver in doses of
gr. :!• to -J in a large claret-glass of water taken on an empty stomach is
useful in some cases.
Many cases of nervous dyspepsia with marked neurasthenic or hysteri-
cal symptoms do well on the Weir-Mitchell treatment, and in obstinate
forms it should be given a thorough trial. The most striking results
are perhaps seen in the cases of anorexia nervosa, which will be referred
to subsequently. It is also of value in the nervous vomiting. In the dis-
tressing cases of hyperacidity, in addition to the treatment of the general
neurotic condition, alkalies must be employed, either in the form of mag-
nesia or bicarbonate of soda. The burning acid eructations are usually
relieved in this way.
Limiting the patient to a strictly meat diet is a valuable procedure
in many cases of dyspepsia associated with hyperacidity. The meat should
be taken either raw or, if an insuperable objection exists to this, very
slightly cooked. It is best given finely minced or grated on stale bread.
An ample dietary is 3 J ounces (100 grammes) of meat, two medium
slices of stale bread, and an ounce (30 grammes) of butter. This may
be taken three times a day with a glass of Apollinaris water, soda water,
or, what is just as satisfactory, spring water. The fluid should not be
taken too cold. Special care should be had in the examination of the
meat to guard against tape-worm infection, but suitable instructions on
this point can be given. This is sufficient for an adult man, and many
obstinate cases yield satisfactorily to a month or six weeks of this treat-
ment, after which time the less readily digested articles of food may be
gradually added to the dietary. In other instances the use of the stom-
ach-tube is most effectual.
There are forms of nervous dyspepsia occurring in women who are
often well nourished and with a good color, yet who suffer — particularly at
night — with flatulency and abdominal distress. The sleep may be quiet
and undisturbed for two or three hours, when they are aroused with pain-
ful sensations in the abdomen and eructations. The appetite and diges-
364 DISEASES OF THE DIGESTIVE SYSTEM.
tiou may appear to be normal. Constipation is, however, usually present.
In many of these patients the condition seems rather intestinal dyspepsia,
and the distress is due to the accumulation of gases, the result of excess-
ive putrefaction. The fats, starches, and sugars should be restricted. A
diastase ferment is sometimes useful. The flatulency may be treated by
the methods above mentioned. jN'aphthalin, salicylate of bismuth, and
salol have been recommended. Some of these cases obtain relief from
thorough irrigation of the colon at bedtime.
V. DILATATION OF THE STOMACH (Gasfrectasis).
Etiology. — This may occur either as an acute or a chronic con-
dition.
Acute dilatation is rarely seen, though it occurs whenever enormous
quantities of food and drink are quickly ingested. Occasionally this leads
to extreme paralytic dilatation, and Fagge has described two cases which
came on in this way, one of which proved fatal.
Chronic dilatation results from : (a) Narrowing of the pylorus or
of the duodenum by the cicatrization of an ulcer, hypertrophic stenosis of
the pylorus (whether cancerous or simple), congenital stricture, or occa-
sionally by pressure from without of a tumor or of a floating kidney, [h)
Relative or absolute insuflftciency of the muscular power of the stomach,
due, on the one hand, to repeated overfilling of the organ with food and
drink ( Ueberanstreiigung des Magens^ Striimpell), and, on the other, to
atony of the coats induced by chronic inflammation or degeneration or
impaired nutrition, the result of constitutional affections, as cancer, tuber-
culosis, anaemia, etc.
The most extreme forms are met with in the first group, and most
commonly as a sequence of the cicatricial contraction of an ulcer. There
may be considerable stenosis without much dilatation, the obstruction being
compensated by hypertrophy of the muscular coats. Considerable atten-
tion has been directed in Germany by Litten, Ewald, and others to the
association of dilatation with dislocation of the right kidney. Two well-
marked instances have come under my observation among a very large
number of cases of movable kidney, but in neither was the dilatation ex-
treme.
In the second group, due to atony of the muscular coats, we must dis-
tinguish between instances in which the stomach is simply enlarged and
those witli actual dilatation, the conditions which Ewald characterized as
megastric and gastrcctasis resi)ectively. The size of the stomach varies
greatly in dilTerent individuals, and the maximum capacity of a normal
organ Ewald places at about 1,G00 c. c. Measurements above this point
indicate absolute dilatation.
Atonic dilatation of the stomach may result from weakness of the
DILATATION OF THE STOMACH. 3G5
coats, clue to repeated overdistcntion or to chronic catarrh of the mucous
membraue, or to the general muscular debility which is associated with
chronic wasting disorders of all sorts. The combination of chronic gastric
catarrh with overfeeding and excessive drinking is one of the most fruit-
ful sources of atonic dilatation, as pointed out by Naunyn. The condition
is frequently seen in diabetics, in the insane, and in beer-drinkers. In
Germany this form is very common in men employed in the breweries,
who sometimes drink from twenty to thirty litres of beer in the day. The
extraordinary size to which the organ attains in some of these cases is
well shown by the papier-mache models which have been prepared under
von Ziemssen's directions. Possibly muscular weakness of the coats may
result in some cases from disturbed innervation. Dilatation of the
stomach is most frequent in middle-aged or elderly persons, but the
condition is not uncommon in children, especially in association with
rickets.
Symptoms. — These are very variable and depend upon the cause
and the degree of dilatation. Naturally the features in cancer of the py-
lorus would be very different from those met with in an excessive drinker.
Dyspepsia is present in nearly all cases, and there are feelings of distress
and uneasiness in the region of the stomach. The patient may complain
much of hunger and thirst and eat and drink freely. The most character-
istic symptom is the vomiting at intervals of enormous quantities of liquid
and of food, amounting sometimes to four or more litres. The material
is often of a dark-grayish color, with a characteristic sour odor due to the
organic acids present, and contains mucus and remnants of food. On
standing it separates into three layers, the lowest consisting of food, the
middle of a turbid, dark-gray fluid, and the uppermost of a brownish froth.
The microscopical examination shows a large variety of bacteria, yeast
fungi, and the sarcina ventriculi. There may also be cherry stones, plum
stones, and grape seeds.
Chemically the hydrochloric acid may be absent, diminished, normal,
or in excess, depending upon the cause of the dilatation. The fermenta-
tion produces lactic, butyric, and, possibly, acetic acids and various gases.
In consequence of the small amount of fluid which passes from the
stomach or is absorbed there are constipation, scanty urine, and extreme
dryness of the skin. The general nutrition of the patient suffers greatly ;
there is loss of flesh and strength, and in some cases the most extreme
emaciation. A very remarkable symptom which occurs occasionally is
tetany, first described by Kiissmaul. The spasm affects chiefly the muscles of
the hands, arms, and legs. Loss of consciousness may occur. The spasms
last for a short time only. Miiller has collected eight cases of the kind,
two of which occurred in simple dilatation of the stomach.
Physical Signs. — Inspection. — The abdomen may be large and promi-
nent, the greatest projection occurring below the navel in the standing
posture. In some instances the outline of the distended stomach can be
366 DISEASES OF THE DIGESTIVE SYSTEM.
plainly seen, the small curvature a couple of inches below the ensiform
cartilage, and the greater curvature passing obliquely from the tip of the
tenth rib on the left side, toward the pubes, and then curving upward
to the right costal margin. There are instances in Avhich inspection
alone reveals, at a glance, the nature of the case. Active peristalsis may
be seen in the dilated organ, the waves passing from left to right. Occa-
sionally anti-peristalsis may be seen. In cases of stricture, particularly of
hypertrophic stenosis, as the peristaltic wave reaches the pylorus, the
tumor-like thickening can sometimes be distinctly seen through the thin
abdominal wall. To stimulate the peristalsis the abdomen may be flipped
with a wet towel.
Falpation. — The peristalsis may be felt, and usually in stenosis the
tumor is evident at the pylorus. The resistance of a dilated stomach is
peculiar, and has been aptly compared to that of an air cushion. Bi-
manual palpation elicits a splashing sound, which is, of course, not dis-
tinctive, as it can be obtained whenever there is much liquid and air in
the organ, but it cannot be obtained in a healthy person two or three
hours after eating. The splashing may be very loud, and the patient may
produce it himself by suddenly depressing the diaphragm, or it may be
readily obtained by shaking him. A tube passed into the stomach may be
felt externally through the skin, a procedure no longer recommended by
Leube, who suggested it.
Percussion. — The note is tympanitic over the greater portion of a
dilated stomach ; in the dependent part the note is dull. In the upright
position the percussion should be made from above downward, in the left
parasternal line, until a change in resonance is reached. The line of this
should be marked, and the patient examined in the recumbent position,
when it will be found to have altered its level. When this is on a line
with the navel or below it, dilatation of the stomach may generally be
assumed to exist. This sign may be deceptive in women with lax abdo-
men, as the whole organ may be depressed, the lesser curvature coming,
perhaps, as low as the navel. The fluid may be withdrawn from the
stomach with a tube, and the dulness so m.ade to disappear, or it may be
increased by pouring in more fluid. In cases of doubt the organ may be
artificially distended with carbonic-acid gas. A teaspoonful of bicarbon-
ate of soda is first given in a little water, and then the same quantity of
tartaric acid. The most accurate method of determining the size of the
stomach is by inflation through a stomach-tube with a Davidson's syringe.
Pacanowski has shown that the greatest vertical diameter of gastric res-
onance in the normal stomach varies from 10 to 14 cm. in the male and is
about 10 cm. in the female.
Auscultation. — The clapotement or succussion can be obtained readily.
Frequently a curious sizzling sound is present, not unlike that heard when
the ear is placed over a soda-water bottle when first opened. It can be
heard naturally, and is usually evident when the artificial gas is being
DILATATION OF THE STOMACH. 3G7
generated. The lieart somids may sometimes be transmitted with great
clearness and with a metallic quality.
Me7is2iraiion may be used by passing a hard sound into the stomach
until the greater curvature is reaclKid. Normally it rarely passes more
than GO cm., measured from the teeth, but in cases of dilatation it may
pass as much as 70 cm.
Diagnosis. — The diagnosis can usually be made without much diffi-
culty by attention to these methods of examination. Curious errors, how-
ever, are on record, one of the most remarkable of which was the con-
founding of dilated stomach with an ovarian cyst ; even after tapping
and the removal of portions of food and fruit seeds, abdominal section
was performed and the dilated stomach opened. The progtiosis is bad
in cases in which there is stenosis of the pylorus, either simple or can-
cerous.
Treatment. — With care, the dilatation consequent upon simple steno-
sis is not incompatible Avith many years of life. In the cases due to atony
careful regulation of the diet and proper treatment of the associated catarrh
will suffice to effect a cure. Strychnine, ergot^ and iron are recommended.
"Washing out the stomach is of great service, though we do not see such
striking and immediate results in this form. In cases of mechanical ob-
struction the stomach should be emptied and thoroughly washed, either
with warm water or with an antise]3tic solution. As Welch states, in his
exhaustive article on this subject, we accomplish in this way three impor-
tant things : We remove the weight, which helps to distend the organ ;
we remove the mucus and the stagnating and fermenting material which
irritates and inflames the stomach and impedes digestion ; and we cleanse
the inner surface of the organ by the application of water and medicinal
substances. The introduction of this method by Kiissmaul, in 1867, has
practically revolutionized the treatment in diseases of the stomach. The
method of application has already been referred to. The patient can
usually be taught to wash out his own stomach, and in a case of dilatation
from simple stricture I have known the practice to be followed daily for
three years with great benefit. The rapid reduction in the size of the
stomach is often remarkable, the vomiting ceases, the food is taken readily,
and in many cases the general nutrition improves rapidly. As a rule,
once a day is sufficient, and it may be practised either the first thing in
the morning or before going to bed. So soon as the fermentative pro-
cesses have been checked, lukewarm water alone should be used.
The food should be taken in small quantities at frequent intervals,
and should consist of scraped beef, Leube's beef solution, and tender
meats of all sorts. Fatty and starchy articles of diet are to be avoided.
Liquids should be taken sparingly.
In cicatricial stenosis of the pylorus Lorcta has practised dilatation
with considerable success. The statistics of Barton show that of 25 pub-
lished cases 15 recovered and 10 died.
368 DISEASES OF THE DIGESTIVE SYSTEM.
VI. THE PEPTIC ULCER-GASTRIC AND DUODENAL.
The round, perforating or simple ulcer is usually single and occurs in
the stomach and in the duodenum as far as the papilla biliaria. It proba-
ably follows nutritional disturbance in a limited region of the mucosa,
which results in the gradual destruction of this area by the gastric juice.
The condition is usually associated with hyperacidity.
Etiology. — Clinically the simple ulcer is not so frequent as the sta-
tistics of post-mortems would lead us to expect ; thus in the extensive rec-
ords collected by Welch ulcer, cicatrized or open, was present in about
five per cent of persons dying from all causes. The scars are found more
frequently than the open ulcer.
Females are more frequently affected than males. Of 1,699 cases col-
lected from hospital statistics by Welch, and examined post mortem, 40
per cent were in males and 60 per cent were in females. He gives the
age incidence in 607 cases, of which three fourths were distributed be-
tween the ages of twenty and sixty, Avith tolerable uniformity in the four
decades. In females the largest number of cases occurs between twenty
and thirty ; in males, between thirty and forty. Ulcer occasionally oc-
curs in children, and Goodhart has reported a case in an infant thirty
hours old. Gastric ulcer is stated to be less common in this country than
in Europe.
In women it is frequent among servant girls, and in men who follow
such occupations as shoe-making, weaving, and tailoring, possibly connect-
ed, as Habershon suggested, with pressure on the stomach. This view
has been developed by Rasmussen, who holds that pressure of the costal
margin, from various causes, induces anaemia and atrophy of the mucous
membrane, particularly in the region of the smaller curvature. Very
rarely the disease originates from traumatism or the action of corrosive
fluids. Gastric ulcer is associated in a special manner with certain dis-
eases, in women with anaemia and chlorosis and with menstrual disorders.
It is not infrequently met with in tuberculosis. Such cases are not, how-
ever, to be mistaken for the true tuberculous ulcer, which may be found in
the stomach.
Mirny cases have occurred in connection with disease of the heart or
of the blood-vessels, a relation of special interest in connection with the
embolic theory of its production.
The duodenal ulcer is less common than the gastric ulcer, and occurs
most frequently in males. The combined statistics of Krauss, Chvostek,
Lebert, and Trier give 171 cases in males and 30 in females. In 9 cases
which have come under my observation 7 were in males and 2 in females ;
one of these was in a lad of twelve. It has been found in association with
tuberculosis, and may follow large superficial burns.
Morbid Anatomy.— Though usually single, the ulcers may be multi-
ple. In none of my cases were there more than five, but there is an instance
THE PEPTIC ULCER— GASTRIC AND DUODENAL. 309
on record of tliirty-four. Tlio ulcer is situated most commonly on the
posterior wall of the j^yloric portion at or near the lesser curvature. It is
not nearly so frequent on the anterior wall. Of 793 cases collected by
AVelch from hospital statistics, 288 were on the lesser curvature, 235 on
the posterior wall, 95 at the pylorus, 69 on the anterior wall, 50 at the
cardia, 29 at the fundus, 27 on the greater curvature. The duodenal
ulcer is usually situated just outside the ring in the first portion of
the gut.
The ulcer varies from 1 to 10 cm. in diameter. It may be small and
punched out, or it may reach an enormous size. The largest of which I
have any knowledge is one reported by Peabody, which measured 19 by
10 cm. and involved all of the lesser curvature and spread over a large
part of the anterior and posterior walls. The ulcer is usually round or
oval in shape, but may be irregular with sinuous borders. It is often dis-
tinctly terraced. In acute cases the mucous membrane is sharply cut, as
if punched out by an instrument. In old cases the edge is indurated and
loses the sharp margin. The floor is formed either by the submucosa, by
the muscular layers, or, not infrequently, by the neighboring organs, to
which the stomach has become attached. In the healing of the ulcer, if
the mucosa is alone involved, the granulation tissue develops from the edges
and the floor and the newly formed tissue gradually contracts and unites
the margins, leaving a smooth scar. In larger ulcers w^hich have become
deep and involved the muscular coat the cicatricial contraction may cause
serious changes, the most important of which is narrowing of the pyloric
orifice and consequent dilatation of the stomach. In the case of a girdle
ulcer, hour-glass contraction of the stomach may be produced. It is prob-
able that large ulcers persist for years without any attempt at healing.
The ulcer may deepen and penetrate the coats. Fortunately, in a
majority of the cases, adhesions form between the stomach and adjacent
organs, particularly with the pancreas, the left lobe of the liver, and the
omental tissues On the anterior surface of the stomach adhesions do not
so readily form, hence the great danger of the ulcer in this situation,
which more readily perforates and excites a diffuse and fatal peritonitis.
On the posterior wall the ulcer penetrates directly into the lesser peri-
toneal cavity, in which case it may produce an air-containing abscess with
the symptoms of the condition known as subphrenic pyo-pneumothorax.
In rare instances adhesions and a gastro-cutaneous fistula form, usually
in the umbilical region. Fistulous communication with the colon may
also occur, or a gastro-duodenal fistula. There are several instances on
record of perforation into the pericardium, and at least two of rupture
into the left ventricle. Perforation into the pleura may also occur. It is
to be noted that general emphysema of the subcutaneous tissues occasion-
ally follows perforation of a gastric ulcer.
One of the most serious effects of gastric ulcer is erosion of blood-ves-
sels. The haimorrhage may occur in the acutely formed ulcer or in the
370 DISEASES OF THE DIGESTIVE SYSTEM.
ulceration which takes place at the base of the chronic form ; it is in
the latter condition that the bleeding is most common. Ulcers on the
posterior wall may erode the splenic artery, but perhaps more frequently
the bleeding proceeds from the artery of the lesser curve. In the case of
duodenal ulcer the pancreatico-duodenal artery may be eroded or (as in
one of my cases) fatal hgemorrhage may result from the opening of the
hepatic artery, or more rarely the portal vein. Interesting changes occur
in the vessels. Embolism of the artery supplying the ulcerated region has
been met with in several cases ; in others diffuse endarteritis. Small
aneurisms have been found in the floor of the ulcers by Douglas Powell,
AVelch, and others.
The mode of the origin of the peptic ulcer has been much discussed.
Ulcers have been produced in animals in many ways, both by artificial
emboli and by direct chemical and mechanical irritants applied to the mu-
cosa. The ulcers thus produced heal with great rapidity unless the ani-
mals have been rendered anaemic by repeated abstraction of blood. Vir-
chow's view that the process may result from plugging the nutrient artery
of the part, either by an embolus or by a thrombus, and the infarct so
produced is destroyed by the gastric juice, has gained general acceptance.
It is in conformity with Pavy's well-known experiments and with the ana-
tomical facts already mentioned, particularly with the funnel-like shape
of the ulcer, and the actual demonstration, in some cases, of the plugged
vessels ; but this view scarcely meets all the cases, in many of which the
etiology is still obscure. Mere mechanical injury to the mucous mem-
brane is, however, in most cases, insufficient cause for an ulcer, for nor-
mally the stomach is perfectly able to withstand such insults. Ewald
concludes that certain predisjiosing causes play an important role in its
development. He points to its frequency in conditions of amenorrhcea,
chlorosis, anaemia after confinements, etc., where one may assume that the
condition of the blood is not wholly normal, and also to the fact that in
the majority of cases of this affection there is a hyperacidity of the gas-
tric juice. One or both of these predisposing factors seem to be pres-
ent in most cases, and it has been recently shown that in the various
anaemia? there is an appreciable diminution in the normal alkalinity of
the blood, a fact which tends to explain one of the predisposing causes
in these affections, and which is in accord with the " alkalescence theory "
of Cohnheim et al. The duodenal ulcer has an identical origin, but a few
cases of acute ulcer, as already mentioned, have a curious relation with
superficial burns. In one of my cases there was an ulcer in the posterior
wall of the duodenum, 1-5 cm. in diameter, with overlapping edges, and
not far from it was a cyst-like cavity in the submucosa associated with
Brunner's glands, and it is possible that the open ulcer, with undermined
edges, resulted from the rupture of one of these cysts.
Symptoms. — The condition may be met with accidentally, post mor-
tem, in cases wliich h.-ive presented no indication of gastric disturbance.
THE PEPTIC ULCER— GASTRIC AND DUODENAL. 371
In other instances the first symptoms may be due to perforation. In
others again the symptoms, for months and years, may be those of ordi-
nary dyspepsia, and the ulcer may not have been suspected until the oc-
currence perhaps of a sudden haemorrhage.
The symptoms suggestive of peptic ulcer are : (a) Dyspepsia, which
may be slight and trifling or of a most aggravated character. In a con-
siderable proportion of all cases nausea and vomiting occur, the latter not
for two or more hours after eating. The vomitus usually contains a large
amount of HCl.
(b) Haemorrhage is present in at least one half of all cases. It may be
slight, but more commonly is profuse, and may be in such quantities and
brought up so quickly that it is fluid, bright red in color, and quite unal-
tered. When the blood remains for some time in the stomach and is
mixed with food it may be greatly changed, but the vomiting of a large
quantity of unaltered blood is very characteristic of ulcer. Syncope
may follow or death may directly result from the hemorrhage. A most
extreme grade of anaemia may be produced. In either the gastric or
duodenal ulcer, more commonly in the latter, the blood may be passed in
the stools and not be vomited. This may occur when the haemorrhage is
slight, but also when it is profuse enough to produce collapse and extreme
anaemia.
(c) Pain is perhaps the most constant and distinctive feature of
ulcer. It varies greatly in character ; it may be only a gnawing or burn-
ing sensation, which is particularly felt when the stomach is empty, and is
relieved by taking food, but the more characteristic form comes on in
paroxysms of the most intense gastralgia, in which the pain is not only
felt in the epigastrium, but radiates to the back and to the sides. These
attacks are most frequently induced by taking food, and they may recur
at a variable period after eating, sometimes within fifteen or twenty min-
utes, at others as late as two or three hours. It is usually stated that
when the ulcer is near the cardia the pain is apt to set in earlier, but there
is no certainty on this point. The attacks may occur at intervals with
great intensity for weeks or months at a time, so that the patient con-
stantly requires morphia, then again they may disappear entirely for a
prolonged period. In the attack the patient is usually bent forward, and
finds relief from pressure in the epigastric region ; one patient during the
attack would lean over the back of a chair ; another would lie flat on the
floor, Avith a hard pillow under the abdomen. Pressure is, as a rule,
grateful. It has been thought that the posture assumed during the attack
would indicate the site of the ulcer, but this is very doubtful.
(d) Tenderness on pressure is a common symptom in ulcer, and pa-
tients wear the waist-band very low. There may be a painful point of
very limited extent, most frequently an inch or two below tlie ensiform
cartilage. In old ulcers with thickened bases an indurated mass can usu-
ally bo felt in the neighborhood of the pylorus. Pressure should be made
372 DISEASES OF THE DIGESTIVE SYSTEM;
with great care, as rupture of an ulcer has been induced by careless
manipulation.
(e) Of general symptoms, loss of weight results from the prolonged
dyspepsia, but it rarely, except in association with cicatricial stenosis of
the pylorus, reaches the high grade met with in cancer. The anaemia may
be extreme, and in one case of duodenal ulcer which I examined the blood
count Avas as low as 700,000 per c. mm. There are instances, such as the
one reported by Pepper and Griffith, in which the extreme anaemia cannot
be explained by the occurrence of haemorrhage.
According to Welch, perforation occurs in about six and a half per
cent of all cases. The acute, perforating form is much more common in
women than in men. The symptoms are those of perforative peritonitis.
In some instances the pain associated with perforation is not referred to
the abdomen. In a case of H. C. Wood's the chief symptoms were pain in
the left shoulder and excessive pain in the back on movement. Per-
foration is not necessarily fatal. Several cases of recovery have been re-
ported.
The course of the disease is, in the majority of cases, chronic. Only a
few instances run a very acute course. The following group of clinical
forms, described by Welch, indicate the diversity of this affection :
" 1. Latent ulcers, with entire absence of symptoms, and revealed as
open ulcers or as cicatrices at the autopsy.
" 2. Acute perforating ulcers. With or without a period of brief gas-
tric disturbance, perforation occurs and causes speedy death.
" 3. Acute haemorrhagic form of gastric ulcer. After a latent or a
brief course of the ulcer, profuse gastrorrhagia occurs, which may termi-
nate fatally or may be followed by the symptoms of chronic ulcer.
" 4. Gastralgic-dyspeptic form. In this, which is the most common
form of gastric ulcer, gastralgia, dyspepsia, and vomiting are the symptoms.
Sometimes one of the symptoms predominates greatly over the others, so
that Lebert distinguishes separately a gastralgic, a dyspeptic, and a vomit-
ive variety. Gastralgia is the most frequent symptom.
" 5. Chronic haemorrhagic form. Gastrorrhagia is a marked symptom,
and occurs usually in combination with the symptoms just mentioned.
" G. Cachectic form. Tliis usually corresponds only to the final stage
of one of the preceding forms, but the cachexia may develop so rapidly
and become so marked that the course of the disease closely resembles that
of gastric cancer.
" 7. Recurrent form. In this the symptoms of gastric ulcer disappear,
and then follow intervals, often of considerable duration, in which there
is apparent cure, but the symptoms return, especially after some indiscre-
tion in the mode of living. This intermittent course may continue for
many years. In these cases it is probable either that fresh ulcers form or
that the cicatrix of an old ulcer becomes ulcerated.
" 8. Stenotic form. By the formation of cicatricial tissue in and
THE PEPTIC ULCER— GASTRIC AND DUODENAL. 373
around tlic ulcer, the pyloric orifice l)ecomos obstructed and the symptoms
of dilatation of the stomach develop."
The course may be very protracted, and there are cases in which the
disease has persisted for over twenty years. I have reported two in-
stances of peptic ulcer, probably duodenal, in which well-marked symp-
toms were present, in one case for eighteen, and in the other for twelve
years. Both were of the chronic hsemorrhagic form.
Diagnosis. — The recognition of gastric ulc*er is in many cases easy,
as the combination of dyspepsia, gastralgic attacks, and h^ematemesis is
very characteristic. Of the symptoms, haemorrhage with the gastralgic
attack is the most characteristic. The distinctions between ulcer and
cancer will be given. The greatest difficulty is offered by certain cases of
gastralgia, which may resemble ulcer very closely, as, with the exception
of the haemorrhage, there is no single symptom which may not be present.
Even with haemorrhage the case may not be clear, and no less an author-
ity than the late Austin Flint made a diagnosis of recurring gastralgia in
a patient who had, on and off for nine years, violent pains with vomit-
ing in association with ulcer. A difficulty also results from the fact that
in many instances gastralgia is one of the symtoms of nervous dyspepsia,
and may exist with marked emaciation.
The following points are of value in discriminating between these two
conditions :
(a) In ulcer the pain is more definitely connected with taking food,
though this is not always the case, as in the duodenal form the gastralgic
attacks may occur at night when the stomach is empty. Relief of pain
after eating is certainly less common in ulcer than in gastralgia, though it
is a very uncertain feature, and in certain cases the pain in ulcer is always
relieved by taking food.
(h) In ulcer dyspeptic symptoms are almost invariably present in the
intervals between the attacks, and even when pain is absent there is slight
distress.
(c) Local sensitiveness in a particular spot in the epigastrium is sug-
gestive of ulcer. External pressure usually aggravates the pain in ulcer,
and often relieves it in gastralgia. This is, however, a very uncertain
feature, as patients writhing with the pains of ulcer may press the abdo-
men over the back of a chair or place a hard pillow under it.
{(l) The general condition and history of the patient often give the
most trustworthy information. The nutrition is impaired more frequent-
ly in ulcer than in gastralgia. In the former we find more commonly
(in women) dysmenorrhoea and chlorosis, while in the latter there are
associated nervous phenomena — hysterical manifestations or neuralgias in
other regions.
(e) On examination of the abdomen, not only is pain on pressure much
more common in ulcer, but there may also be thickening about the pylo-
rus and, in many cases, signs of dilatation of the stomach.
374 DISEASES OF THE DIGESTIVE SYSTEM.
(/) Hyperacidity of the gastric juice exists with ulcer.
The gastric crises which occur in affections of the spinal cord, particu-
larly in locomotor ataxia, may simulate very closely the gastralgic attacks
of ulcer, and as they so often exist in the preataxic stage their true
nature may be overlooked ; but the occurrence of lightning pains, the ocu-
lar symptoms, and the absence of the knee reflex are indications usually
sufficient to render the diagnosis clear.
Can the gastric and duodenal ulcer be distinguished clinically? As
already stated, they originate in the same way and present the same ana-
tomical characters. In the great majority of cases they cannot be sepa-
rated during life, as the symptoms produced are identical. Bucquoy has
suggested that the duodenal ulcer can be divstinguished by the following
definite characters : {a) Sudden intestinal hemorrhage in an apparently
healthy person, which tends to recur and produce a profound ansemia.
Haemorrhage from the stomach may precede or accompany the melaena.
{h) Pain in the right hypochondriac region, coming on two or three hours
after eating, [c) Gastric crises of extreme violence, during which the
haemorrhage is more apt to occur. Certainly the occurrence of sudden in-
testinal haemorrhage with gastralgic attacks is extremely suggestive of duo-
denal ulcer. W. W. Johnston has reported an instance in which he made
the diagnosis on these symptoms, and in one of the Montreal cases Palmer
Howard suggested correctly the presence of a duodenal ulcer on similar
grounds. A patient under my care who had, during eighteen years, fre-
quent attacks of haematemesis with gastralgia had melaena repeatedly with-
out vomiting blood ; * but as a rule in the attacks the blood was vomited
first, and did not appear in the stools until later. Occasionally this sym-
ptom will be found an important aid in diagnosis. The situation of the
pain is too uncertain a factor on which to lay much stress, and the char-
acter of the crises is usually identical.
Gall-stone colic may occasionally simulate the pains of gastric ulcer.
The sudden onset and as sudden termination, the swelling and tenderness
of the liver, the enlargement of the gall-bladder, if j)resent, and the oc-
currence of jaundice are points which usually make the diagnosis clear.
Treatment. — Post-mortem observations show that a very large num-
ber of ulcers heal completely, but the process is slow and tedious, often
requiring months, or, in severe cases, years. The following are the im-
portant points in treatment :
{a) Absolute rest in bed.
{!)) A carefully and systematically regulated diet. While theoretically
it is better to give the stomach complete rest by rectal feeding, yet in
practice this strict limitation is not found satisfactory. The food should
be bland, easily digested, and given at stated intervals. The following
dietary will be found useful : At 8 A. M. give 200 c. c. of Leube's beef solu-
* On tlic Diagnosis of Duodenal Ulcer, Medical Record, November 24, 1888.
THE PEPTIC ULCER-GASTRIC AND DUODENAL. 375
tion ; at 12 m., 300 c. c. of milk gruel or peptonized milk. The gruel
should be made with ordinary flour or arrowroot, and is mixed with an
equal quantity of milk. If necessary it may be peptonized. Buttermilk
is very well borne by these patients. • At 4 P. M. the beef solution again,
and at 8 p. m. the milk gruel or the buttermilk.
The stomach in some cases is so irritable that the smallest amount
of food is not well borne. In such cases lavage may be practised, if neces-
sary, every morning and evening, with mildly alkaline water, after which
the beef solution is given and the feeding supplemented by the rectal in-
jections. Ill effects rarely follow the careful use of the stomach tube in
gastric ulcer. There are some cases which do Avell from the outset on a
milk diet, given at regular intervals, three or four ounces every two hours.
When milk is not well borne egg albumen may be substituted, or the whites
of eight eggs may be alternated with Leube's beef solution. At the end
of a month, if the condition has improved, the patient may be allowed
scraped beef or young chicken, perfectly fresh sweet-bread, and farina-
ceous puddings made with milk and eggs. Local applications, such as
warm fomentations, over the abdomen are very useful. The patient should
be told that the treatment will take at least three months, and for the
greater portion of the time he should be in bed.
(c) Medicinal measures are of very little value in gastric ulcer, and
the remedies employed do not probably benefit the ulcer, but the gastric
catarrh. The Carlsbad salts are w^armly recommended by von Ziems-
sen. The artificial preparation (sulphate of sodium, 50 ; bicarbonate of
sodium, 6 ; chloride of sodium, 3) may be substituted, of which a tea-
spoonful is taken every morning. Bismuth, in doses of thirty to
sixty grains three times a day, and nitrate of silver may be given, but
they influence the associated conditions rather than the ulcer.
The pain if severe requires opium. Unless the gastralgia is intense
morphia should not be given hypodermically, as there is a very serious
danger in these cases of establishing the morphia habit. Doses of an
eighth of a grain, with the bicarbonate of soda and bismuth, will allay the
mild attacks, but the very severe ones require the hypodermic injection of
a quarter or often half a grain. Antipyrin and antifebrin may be tried,
but, as a rule, are quite ineffectual. In the milder attacks Hoffman's
anodyne, or twenty or thirty drops of chloroform, or the spirits of camphor
will give relief. Counter-irritation over the stomach with mustard or
cantharides is often useful.
For the vomiting there is no measure so successful as lavage. If in-
tractable the patient must be fed per rectum. The patient will sometimes
retain food which is passed into the stomach through the tube, and
Leube's beef solution or milk may be given in this way. Cracked ice,
chloroform, oxalate of cerium, bismuth, hydrocyanic acid, and ingluvin
may be tried. When haemorrhage occurs the patient should be put under
the influence of opium as rapidly as possible. No attempt should be made
376 DISEASES OF THE DIGESTIVE SYSTEM.
to check the haemorrhage by administering medicines through the mouth ;
as the profuse bleeding is always from an eroded artery, frequently from
one of considerable size, it is doubtful if acetate of lead, tannic and
gallic acids, and the usual remedies have the slightest influence. The
essential point is to give rest, which is best obtained by opium. Er-
gotin may be administered hypodermically in two-grain doses. Nothing
should be given by the mouth except small quantities of ice. In profuse
bleeding a ligature may be applied around a leg, or a leg and arm. Kot
infrequently the loss of blood is so great that the patient faints. A fatal
result is not, how^ever, very common from haemorrhage. Transfusion may
be necessary, or, still better, the subcutaneous infusion of saline solution.
The patients usually recover rapidly from the haemorrhage and require
iron in full doses, which may, if necessary, be given hypodermically.
VII. CANCER OF THE STOMACH.
Etiology. — The stomach comes next to the uterus as the most fre-
quent seat of primary cancer, amounting, as shown by the statistics of
Welch,* to 21-4 per cent in a total of over 30,000 cases. The ratio of
males to females affected is about five to four. Age has an important
bearing. Of 2,038 cases tabulated by this author three fourths occurred
between the fortieth and the seventieth year, 24*5 per cent between the
ages of forty and fifty, and 30*4 between the ages of fifty and sixty. In
childhood it is extremely rare. Cancer of the stomach is a very common
disease in this country, though statistics would indicate that it is rather
less frequent than in Europe. With reference to heredity, Welch analyzed
1,744 cases and found that a family history was present in 243. Local
conditions, such as chronic gastritis and traumatism, have been thought
by some to be important factors. Cancer may develop in a simple
ulcer of the stomach, but this sequence is extremely rare. It is not
probable that depressing emotions, mode of life, or previous disease have
any influence wJiatever in the causation of cancer.
Morbid Anatomy. — The most common varieties of gastric cancer
are the cylindrical-celled epithelioma and the encephaloid ; next in fre-
quency is scirrhous, and then colloid cancer. With reference to the situa-
tion of the tumor, Welch analyzed 1,300 cases, in which the distribution
was as follows : Pyloric region, 791 ; lesser curvature, 148 ; cardia, 104 ;
posterior wall, 08 ; the whole or greater part of the stomach, Gl ; multiple
tumors, 45 ; greater curvature, 34 ; anterior wall, 30 ; fundus, 19.
The medullary cancer occurs in soft masses, which involve all the coats
of the stomach and usually ulcerate early. The tumor may form villous
projections or cauliflower-like outgrowths. It is soft, grayish white in color,
* System of Medicine, vol. ii, Philadelphia, 188G.
CANCER OP THE STOMACH. 377
and contains much blood. Microscopically it shows a scanty stroma, en-
closing alveoli which contain irregular polyhedral and cylindrical cells.
The cylindrical-celled epithelioma may also form large irregular masses,
but the consistence is usually firmer, particularly at the edges of the can-
cerous ulcers. Microscopically the section shows elongated tubular spaces
filled with columnar epithelium, and the intervening stroma is abundant.
Cysts are not uncommon in this form. The scirrhous variety is character-
ized by great hardness, due to the abundance of the stroma and the limited
amount of alveolar structures. It is seen most frequently at the pylorus,
where it is a common cause of stenosis. It may be combined with the
medullary form. The colloid cancer is peculiar in its wide-spread inva-
sion of all the coats. It also spreads with greater frequency to the neigh-
boring parts, and it occasionally causes extensive secondary growths of the
same nature in other organs. The appearance on section is very distinct-
ive, and even with the naked eye large alveoli can be seen filled with the
translucent colloid material. The term alveolar cancer is often applied to
this form. Ulceration is not constantly present, and there are instances
in which, with most extensive disease, digestion has been very slightly dis-
turbed. There is a specimen in the Warren Museum, at the Harvard
Medical School, of the most wide-spread colloid cancer, in which the
stomach contained after death large portions of undigested beef -steak.
Secondary cancer may also occur in the stomach. Welch has collected
37 cases, 17 of which were secondary to cancer of the breast. The cancer
may produce important changes in the position and shape of the organ,
particularly when the orifices are involved ; thus, a cancer at the cardia
may be associated with wasting of the organ and reduction in its size.
The oesophagus above the obstruction may be greatly distended. On the
other hand, annular cancer at the pylorus may cause stenosis and great
dilatation of the organ ; not necessarily, however, as there are instances on
record in which the pylorus has been extremely narrowed without any in-
crease in the size of the stomach. In scirrhous cancer the organ may be
very greatly thickened and contracted. The stomach may be displaced
or altered in shape by the weight of the tumor, particularly in cancer
of the pylorus, which has been found in every region of the abdomen,
and even in the true pelvis. The mobility of the tumors is at times ex-
traordinary and very deceptive. There was in the Philadelphia Hospital
an old man with a tumor at the pylorus the size of a cricket ball, which
was usually in the epigastric region, but could be pushed into the right
hypochondria or into the splenic region entirely beneath the ribs. Adhe-
sions very frequently occur, particularly to the colon, the liver, and the
anterior abdominal wall.
Secondary cancc^rous growths are very frequent, as shown by the fol-
lowing analysis by Welch of 1,574 cases: Metastasis occurred in the lym-
phatic glands in 551 ; in the liver in 475 ; in the peritonaeum, omentum,
and intestine in 357 ; in the pancreas in 122 ; in the pleura and lung in
25
378 DISEASES OF THE DIGESTIVE SYSTEM.
98 ; in the spleen in 2G ; in the brain and meninges in 9 ; in other parts in
92. The lymph glands affected are usually those of the abdomen, but the
cervical and inguinal glands are not infrequently attacked, and give an
important clew in diagnosis. Occasionally, a secondary metastatic growth
occurs subcutaneously, either at tlie navel or beneath the skin in the vicin-
ity. In an instance recently under observation in a patient with jaundice,
which developed somewhat suddenly and was believed to be catarrhal, there
were no signs of enlargement of the liver or tumor of the stomach, but a
nodular body developed at the navel, which on removal proved to be typi-
cal scirrhus. A second case in the ward at the same time, with an ob-
scure doubtful tumor in the left hypochondria, developed a painful nodu-
lar subcutaneous growth midway between the navel and the left margin of
the ribs.
In the extensive ulceration which occurs perforation of the stomach is
not uncommon. It occurred into the peritona3um in 17 of the 507 cases of
cancer of the stomach collected by Brinton. When adhesions form, the
most extensive destruction of the walls may take place without perfora-
tion into the peritoneal cavity. In one instance which came under my
observation a large portion of the left lobe of the liver lay within the
stomach. Occasionally a gastro-cutaneous fistula is established. Perfora-
tion may occur into the colon, the small bowel, the pleura, the lung, or
into the pericardium.
Symptoms. — Cancer of the stomach may not produce symptoms
other than gradual failure of health, and death may take place from
asthenia without any suspicion of the existence of malignant disease.
These cases are not uncommon, particularly in elderly persons in institu-
tions. In a great majority of all cases there are very definite symptoms,
but the disease presents a very diverse clinical picture. Certain general
features stand out with special jDrominence. The onset is insidious, some-
times with gastric disturbance, but more commonly with impairment of
health and strength. A dyspepsia which may have been troublesome for
years becomes aggravated. Ewald, however, states that dyspeptic symp-
toms are rare prior to the onset of gastric cancer. There are attacks of
nausea and vomiting, and there is pain in the region of the stomach,
which is aggravated by taking food. The patient emaciates, the anaemia
becomes pronounced, and the prostration may be extreme. With slight
intermissions the course is progressively downward, and from month to
month the loss is striking. The face has a sallow cachectic appearance,
the autTmia becomes more intense, and there may be a^dema of the
ankles. Blood may be present in the vomited matter. If with these
general features a tumor can be felt in the region of the stomach the
diagnosis is rendered certain. The course, in rapid cases, may be from
three to six months, but as a rule the disease extends from eighteen months
to two years.
Dyspepsia is common at the outset, but in so many cases the patients
CANCER OP THE STOMACH. 379
have had indigestion for years that the trouble is supposed at first to be
only an aggravation of the chronic complaint. Loss of the desire for
food is a very frequent symptom. There are exceptional instances, how-
ever, in which the appetite is retained throughout, and the functions of
the stomach very slightly disturbed. Nausea is a striking feature in many
cases, and is much more common than in ulcer. There may even be a
sudden repulsion at the sight of food.
Vomiting^ which is one of the most constant symptoms of cancer of
the stomach, may come on earl}^, or only after the dyspepsia has persisted
for some time. At first it is at long intervals, but subsequently it is more
frequent, and may recur several times in the day. There are cases in
which it comes on in paroxysms and then subsides ; in other cases, it sets
in early, persists with great violence, and may cause a fatal termination
within a few weeks. Vomiting is more frequent when the cancer involves
the orifices, particularly the pylorus, in which case it is usually delayed
for an hour or more after taking the food. When the cardiac orifice is
involved it may follow at a shorter interval. Extensive disease of the
fundus or of the anterior or posterior wall may be present without the
occurrence of vomiting. The vomited matters consist of food and mucus
in a grayish or dark sour-smelling fluid. The food is sometimes very
little changed, even after it has remained in the stomach for twent^^-four
hours.
Hcemorrhage is a frequent symptom, but the bleeding is rarely profuse ;
more commonly there is slight oozing, and the blood is mixed with, or
altered by the secretions, and when vomited the material is dark brown
or black, the so-called " coffee-ground " vomit. This is present in a con-
siderable proportion of all cases of cancer, and is an important indication.
The blood can be recognized by the microscope as shells of the red blood-
corpuscles and irregular masses of altered blood pigment. In cases of
doubt the spectroscope may be employed or haemin crystals obtained.
Fragments of the tumor are rarely found in the vomit, and of the
numerous specimens which I have had occasion to examine I have never
been able to satisfy myself of the existence of cancerous tissue. As
Rosenbach states, in the material washed out with the stomach-tube un-
doubted fragments may be found. The yeast fungus, various bacteria,
and the sarcina ventriculi may be present, the latter not so often in cancer
as in dilatation.
Great stress has been laid of late years upon the absence of free
hydrochloric acid in the secretions. As an outcome of the enormous
number of observations which have recently been made it may be said
that free hydrochloric acid is absent in a majority of cases of cancer of
the stomach. This defect is associated with impairment of the secreting
function of the organ. The examination should be made repeatedly, by
the methods already referred to, and with our present knowledge tlie per-
sistent absence of free llCl in the stomach contents, taken in conjunc-
3S0 DISEASES OF THE DIGESTIVE SYSTEM.
tion with other symptoms, may be regarded as highly suggestive of cancer.
Unfortunately, the free acid may be absent in certain other conditions,
such as atrophy, and occasionally in chronic gastritis, so that it is of
greater value from the negative standpoint. As Kinnicutt expresses it,
*' the presence of free HCl in the stomach contents in repeated examina-
tions in doubtful cases is of the greatest diagnostic A^alue, and points
very certainly to absence of cancer." Rosenheim has recently shown that
in cases in which cancer develops in the base of an old ulcer HCl may
be present throughout the course.
Pain is an early and important symptom. It is very variable in situa-
tion, and while most common in the epigastrium, it may be referred to
the shoulders, the back, or the loins. The pain is described as dragging,
burning, or gnawing in character, and very rarely occurs in severe
paroxysms of gastralgia, as in gastric ulcer. As a rule, the pain is
aggravated by taking food. There is usually marked tenderness on
pressure in the epigastric region. It is, however, remarkable how many
cases run a painless course.
H\\Q physical examination oi the abdomen reveals in many instances
the presence of a tumor. Inspection may show a nodular mass in the
epigastrium, or the outlines of a dilated stomach, with peristaltic action.
In the palpation of the stomach it is important to bear in mind cer-
tain anatomical points. At least two thirds of the organ lie in the left
hypochondrium beneath the ribs, and so are practically out of reach.
The pyloric orifice lies to the right of the median line, particularly
when the stomach is full, in which case it may be reached. It is about
on a level with the inner extremity of the eighth right costal cartilage.
The pylorus is movable and changes considerably in position with the
distention of the stomach. Practically, in health there is available for
palpation only a part of the anterior surface of the stomach and the
pylorus, which is sometimes, but not always, overlapped by the liver.
Tumors limited to the cardia, even when extensive, cannot be felt at all.
Tumors involving the fundus, the posterior wall, and the greater part of
the lesser curvature cannot be detected unless very large. Tumors of the
pylorus, of the anterior wall, and of a large part of the greater curvature
are in accessible situations. In the examination the knees should be
drawn up, and the patient asked to relax the abdominal walls as much as
possible. Sometimes, when nothing can be felt on quiet breathing, a
deep inspiration will force down the stomach and bring a tumor mass
within reach. Examination should also be made in the knee-elbow posi-
tion. Cancerous tumors of the stomacli are usually felt in the epigastric
region, but a mass at the pylorus may be felt in the umbilical region,
or, in cases of extreme mobility, in a hypochondriac region, or, very ex-
ceptionally, low down in the iliac region. The tumor is usually firm,
hard, nodular, and painful on pressure. At the pylorus the mass may
be rounded, ball-like, and readily grasped. Gas may sometimes be felt
CANCER OF THE STOMACH. 381
bubbling through it. Communicated pulsation from the aorta is not at
all uncommon. Inflation of the stomach with gas is often a valuable aid
in diagnosis. A teaspoonful of bicarbonate of soda is first given in water,
followed by the same amount of tartaric acid. The distention of the
stomach which follows may suffice to bring tumor masses into reach.
Careful examination should be made to determine the presence of sec-
ondary cancer of the liver or involvement of the lymph glands in the groins
or in the supraclavicular spaces. As already mentioned, the development
of nodules about the navel may give an important hint, or there may be
signs of secondary involvement of the peritonaeum.
Intestinal symptoms are not very common. Constipation is more fre-
quently present than diarrhoea, w^hich may, how^ever, set in and prove ob-
stinate toward the end. AVhen there is much bleeding the stools may be
dark in color.
A progressive ancemia is one of the most striking features of gastric
cancer. As a rule the blood-count does not fall below fifty per cent. A
leucocytosis is almost constantly present, and AVelch has noted an instance
in which the ratio of white to red corpuscles was one to twenty. There
are instances in which the clinical picture is rather that of a pernicious
anaemia, with reduction of the red blood-corpuscles to twenty-five per cent
and marked poikilocytosis. AVhen any degree of anemia is present nucle-
ated red corpuscles may be found in dried and stained specimens, and this
method of examination may be of much service when an actual blood-
count is impossible. The condition is, however, an anaemia with wasting,
and the layer of panniculus is not retained as in the ordinary forms of per-
nicious anaemia. Ultimately the patient develops an aspect to which the
term cachectic is applied, and which is perhaps more marked in gastric
cancer than in any other disease. There may be a slight yellowish tint to
the skin, and it is not uncommon to see brownish stains, the cachectic
chloasma.
Associated with the anaemia and directly dependent upon it are the
dropsical symptoms so common in this affection. CEdema of the ankles
and of the legs is present and may progress to a general anasarca ; the
cases may be mistaken for heart-disease or dropsy. There are no special
cardiac symptoms ; the pulse becomes rapid and feeble toward the end.
The anaemia may, however, produce such palpitation and dyspnoea that
the case may be regarded as cardiac. Thrombosis of a femoral vein may
occur.
The urine may contain a trace of albumen and, toward the close,
tube-casts. Indican is often present in increased quantity, and occasion-
ally acetone and diacetic acid.
The temperature is usually normal, and toward the end, when cachexia
is well marked, subnormal. There are, however, interesting paroxysmal
elevations of temperature, definite chills with fever, in which the ther-
mometer registers 103° or 104°, followed by profuse sweating. The rigors
382
DISEASES OF THE DIGESTIVE SYSTEM.
may recur at intervals for weeks, and, if no tumor is felt, may complicate
the diagnosis. In a case at the Philadelphia Hospital the paroxysms re-
curred for more than six weeks. The autopsy showed a cancer of the
stomach with adhesions to the colon and extensive suppuration at the base
of the cancer and in a pocket between the stomach and omentum.
The mind usually remains clear to the close. Naturally the patient
has attacks of despondency. Toward the close delirium is common. A
form of coma resembling that which occurs in diabetes is occasionally
met with in gastric cancer. The patient becomes restless or excited, and
gradually unconsciousness supervenes, with or without dyspnoea. It is
due to the presence of some toxic agent in the blood, possibly the diace-
tic acid.
Among symptoms referable to the development of secondary growths
those pertaining to the liver are most important. Jaundice is not uncom-
mon, and there may be signs of great enlargement of the liver. Many
instances which are clinically recorded as primary cancer of this organ are
in reality secondary to latent cancer of the stomach. The importance
of enlargement of the supra-clavicular and inguinal glands in gastric can-
cer has already been emphasized. The new growths may extend to the
peritonaeum and, if there is much effusion, produce ascites. Reference
has been made to the perforations liable to occur in gastric cancer. The
course of the disease is progressively downward. In the majority of all
cases death occurs within two years, and the average duration is not more
than eighteen months. In cases of scirrhus the progress is slower.
Diagnosis. — When a tumor is present there is not much difficulty
in determining the nature of the trouble ; even in its absence the pro-
gressive emaciation, the loss of energy and strength, the anaemia and
cachexia, when associated with marked gastric symptoms, are almost path-
ognomonic. There are many instances, however, in which a positive diag-
nosis is impossible. The diseases with which cancer is most liable to be
confounded are ulcer and chronic gastric catarrh, and the differential
features are so well drawn in the elaborate article by my colleague Welch
that I here append them : *
CHRONIC CATARRHAL
GASTRITIS.
GASTRIC CANCER.
GASTRIC ULCER.
1. Tumor is present
in three fourths of the
cases.
2. Rare under forty
years of age.
1. Tumor rare.
2. May occur at any
age after childhood.
Over one half of the
cases under forty years
of age.
1. No tumor.
2. May occur at any
age.
Op. cit., vol. ii, p. 570.
CANCEll OF TUE STOMACH.
383
GASTRIC CAN'CER.
3. Average duration
about one year, rarely
over two years.
4. Gastric haemor-
rhage frequent, but
rarely profuse ; most
common in the cachec-
tic stage.
5. Vomiting often
has the peculiarities of
that of dilatation of the
stomach.
G. Free hydrochloric
acid usually absent from
the gastric contents in
cancerous dilatation of
the stomach.
7. Cancerous frag-
ments may be found in
the washings from the
stomach or in the vomit
(rare).
8. Secondary can-
cers may be recognized
in the liver, the perito-
naeum, the lymphatic
glands, and rarely in
other parts of the body.
9. Loss of flesh and
strength and develop-
ment of cachexia usu-
ally more marked and
more rapid than in ul-
cer or in gastritis, and
less explicable by the
gastric symptoms.
10. Epigastric pain
is often more continu-
ous, less dependent up-
on taking food, less re
GASTRIC ULCER.
3. Duration indefi-
nite ; may be for sev-
eral years.
4. Gastric haemor-
rhage less frequent than
in cancer, but oftener
j^rofuse ; not uncom-
mon v/hen the general
health is but little im-
paired.
5. Vomiting rarely
referable to dilatation
of the stomach, and
then only in a late
stage of the disease.
6. Free hydrochloric
acid usually present in
the gastric contents.
7. Absent.
CintONIC CATAIllUIAL
GASTRITIS.
3. Duration indefi-
nite.
4. (jiastric haemor-
rhage rare.
8. Absent.
9. Cachectic appear-
ance usually less marked
and of later occurrence
than in cancer,and more
manifestly dependent
upon the gastric disor-
ders.
10. Pain is often
more paroxysmal, more
influenc(id by taking
food, oftener relieved
5. Vomiting may or
may not be present.
6. Free hydrochloric
acid may be present or
absent.
7. Absent.
8. Absent.
9. AYhen uncompli-
cated, usually no ap-
pearance of cachexia.
10. The pain or dis-
tress induced by taking
food is usually less se-
vere than in cancer or
384
DISEASES OF THE DIGESTIVE SYSTEM.
GASTRIC CANCER.
lieved by vomiting, and
less localized than in
ulcer.
11. Causation not
known.
GASTRIC ULCER.
by vomiting, and more
sharply localized than
in cancer.
11. Causation not
known.
12. No improve-
ment, or only tempo-
rary improvement, in
the course of the dis-
CIIROXIC CATARRHAL
GASTRITIS.
ulcer. Fixed point of
tenderness usually ab-
sent.
11. Often referable
to some known cause,
such as abuse of alco-
hol, gormandizing, and
certain diseases, as
phthisis, Bright's dis-
ease, cirrhosis of the
liver, etc.
12. May be a history
of previous similar at-
tacks. More amenable
to regulation of diet
than is cancer.
12. Sometimes a his-
tory of one or more pre-
vious similar attacks.
The course may be ir-
ease. regular and intermit-
tent. Usually marked
improvement by regula-
tion of diet.
Treatment. — The disease is incurable and palliative measures are
alone indicated. The diet should consist of readily digested substances of
all sorts. Many patients do best on milk alone. Washing out of the
stomach, which may be done with a soft tube without any risk, is particu-
larly advantageous when there is obstruction at the pylorus, and is by far
the most satisfactorv means of combatting the vomiting:. The excessive
fermentation is also best treated by lavage. When the pain becomes se-
vere, particularly if it disturbs the rest at night, morphia must be given.
One eiglith of a grain, combined with carbonate of soda (gr. v), bismuth
(gr. v-x), usually gives prompt relief, and the dose does not always re-
quire to be increased. Creosote (tti j-ij) and carbolic acid are very useful.
The bleeding in gastric cancer is rarely amenable to treatment. Opera-
tive measures have been advised and practised, and in exceptional in-
stances there are cases in which the limited cancer could be resected with
reasonable hope of recovery.
Non - cancerous tumors of the stomach rarely cause inconvenience.
Polf/pi are common and they may be numerous ; as many as one hundred
and fifty have been reported in one case. Sarcomata are very rare. Fi-
bromata and lipomata have been described.
Foreign bodies occasionally produce remarkable tumors of the stom-
ach. The most extraordinary is the hair tumor, of which a number of
instances have been reported in hysterical women who have been in the
habit of eating their own hair. A specimen in the medical museum of
II^MORRnAGE FROM TIIP] STOMACH. 385
McGill University is in two sections, which form an exact mould of tlie
stomach. The tumors wliich they form are large and very puzzling and
have hecn mistaken for cancer. In one instance the hall of hair was re-
moved by a surgical operation. The tumor was thought to be a movable
kidney.
VIII. HEMORRHAGE FROM THE STOMACH (HcBmatemesLs).
Etiology. — Gastrorrhagia, as this symptom is called, may result from
many conditions, some of which are local, others general.
1. In local disease in the stomach itself: (a) Cancer; (Z») ulcer; (c)
disease of the blood-vessels, such as miliary aneurisms of the smaller arte-
ries, and occasionally varicose veins ; (d) acute congestion, as in gastritis,
and possibly in vicarious haemorrhage, but both of these are extremely
rare causes.
2. Passive congestion due to obstruction in the portal system. This
may be either (a) hepatic, as in cirrhosis of the liver, thrombosis of the
portal vein, or pressure upon the portal vein by tumor, and secondarily in
cases of chronic disease of the heart and lungs ; (b) splenic. Gastrorrhagia
is by no means an uncommon symptom in enlarged spleen, and is ex-
plained by the intimate relations w^hich exist between the vasa brevia and
the splenic circulation.
3. Toxic : («) The poisons of the specific fevers, small-pox, measles,
yellow fever ; (b) poisons of unknown origin, as in acute yellow atrophy
and in purpura ; (c) phosphorus.
4. Traumatism : [a) Mechanical injuries, such as blows and wounds,
and occasionally by the stomach-tube ; (b) the result of severe corrosive
poisons.
5. Certain constitutional diseases : (a) Haemophilia ; (b) profound
anaemias, whether idiopathic or due to splenic enlargements or to malaria ;
(c) cholaemia.
6. In certain nervous affections, particularly hysteria, and occasionally
in progressive paralysis of the insane and epilepsy.
7. The blood may not come from the stomach, but flow into it. Thus
it may pass from the nose or the pharynx. In haemoptysis some of the
blood may find its way into the stomach. The bleeding may take place
from the OBSophagus and trickle into the stomach, from wliich it is eject-
ed. This occurs in the case of rupture of aneurism and of the oesopha-
geal varices. A child may draw blood with the milk from the mother's
breast even in considerable quantities and then vomit it.
8. Miscellaneous causes : Aneurism of the aorta or of its branches
may rapture into the stomach. There are instances in wliich a patient
has a single attack of haemorrhage without even having a recurrence or
without symptoms pointing to disease of the stomach.
3SG DISEASES OF THE DIGESTIVE SYSTEM.
lu new-born infants haemorrhage may occur within the first two wrecks
and prove rapidly fatal ; the precise etiology of this is not known. This
rnclwna neonatorum^ according to Hecker, occurs in one of every five
liundred infants. In a few instances it seems to be associated with an
acquired or hereditary haemophilia. Occasionally it is met with in sound,
healthy infants ; in others the birth has been premature, and in such
cases the bleeding may be associated with premature interruption of the
foetal circulation. In very exceptional cases ulcer of the stomach has
been found.
In medical practice, haemorrhage from the stomach occurs most fre-
quently in connection with cirrhosis of the liver and ulcer of the stomach.
It is more frequent in women than in men, owing to the greater preva-
lence of round ulcer in the former.
Morbid Anatomy. — When death has occurred from the haemate-
mesis there are signs of intense anaemia. The condition of the stomach
varies extremely. The lesion is evident in cancer and in ulcer of the
stomach. It is to be borne in mind that fatal haemorrhage may come
from a small miliary aneurism communicating with the surface by a pin-
hole perforation, or the bleeding may be due to the rupture of a sub-
mucous vein and the erosion in the mucosa may be small and readily
overlooked. It may require a careful and prolonged search to avoid over-
looking such lesions. In the large group associated with portal obstruc-
tion, whether due to hepatic or splenic disease, the mucosa is usually pale,
smooth, and shows no trace of any lesion. In cirrhosis, fatal by haemor-
rhage, one may sometimes search in vain for any focal lesion to account
for the gastrorrhagia, and we must conclude that it is possible for even
the most profuse bleeding to occur by diapedesis. The stomach may be
distended with blood and the source of the haemorrhage not apparent
either in the stomach or in the the portal system. In such cases the
oesophagus should be examined, as the bleeding may come from that
source. In toxic cases there are invariably haemorrhages in the mucous
membrane itself.
Symptoms. — In rare instances fatal syncope may occur without any
vomiting. In a case of the kind, in which the woman had fallen over and
died in a few minutes, the stomach contained between three and four
pounds of blood. The sudden profuse bleedings rapidly lead to profound
anaemia. When due to ulcer or cirrhosis the bleeding usually recurs for
several days. Fatal haemorrhage from the stomach is met with in ulcer,
cirrhosis, enlargement of the spleen, and in instances in which an aneur-
ism ruptures into the stomach or (esophagus. Gastrorrhagia may occur
in splenic anaemia or in leukaemia before the condition has aroused the
attention of friends or physician.
The amount of blood lost is very variable, and in the course of a day
the patient may bring up three or four pounds, or even more. In a
case under the care of George Ross, in the Montreal General Hospital, the
IliEMORRliAGE FROM THE STOMACH. 387
patient lost during seven days ten pounds, by measurement, of blood.
The usual symptoms of anaemia develop rai)idly, and there may be flight
fever, and subsequently oedema may occur. An interesting circumstance
connected with gastro-intestinal hasnlorrhage is the development of amau-
rosis, the mode of production of which is still under discussion.
Diagnosis. — In a majority of instances there is no question as to
the origin of the blood. Occasionally it is difficult, particularly if the
case has not been seen during the attack. Examination of the vomit
readily determines whether blood is present or not. The materials vom-
ited may be stained by Avine, the juice of strawberries, raspberries, or cran-
berries, which give a color very closely resembling fresh blood, while iron
and bismuth and bile may produce a blackish color like altered blood.
In such cases the microscope will show clearly the presence of the shadowy
outlines of the red blood-corpuscles, and, if necessary, spectroscopic and
chemical tests may be applied.
Deception is sometimes practised by hA'sterical patients, who swallow
and then vomit blood or colored liquids. AVith a little care such cases can
usually be detected. The cases must be excluded in which the blood
passes from the nose or pharynx, or in which infants swallow it with the
milk.
There is not often difficulty in distinguishing between haemoptysis and
haematemesis, though the coughing and the vomiting are not infrequently
combined. The following are points to be borne in mind in the diagnosis :
H^MATEMESIS. HEMOPTYSIS.
1. Previous history points to gas- 1. Cough or signs of some pul-
tric, hepatic, or splenic disease. monary or cardiac disease precedes,
in many cases, the haemorrhage.
2. The blood is brought up by 2. The blood is coughed up,
vomiting, prior to which the patient and is usually preceded by a sensa-
may experience a feeling of giddi- tion of tickling in the throat. If
ness or faintness. vomiting occurs, it follows the
coughing.
3. The blood is usually clotted, 3. The blood is frothy, bright
mixed with particles of food, and red in color, alkaline in reaction,
has an acid reaction. It may be If clotted, rarely in such large co-
dark, grumous, and fluid. agula, and muco pus may be mixed
with it.
4. Subsequent to the attack the 4. The cough persists, physical
patient passes tarry stools, and signs signs of local disease in the chest
of disease of the abdominal viscera may usually be detected, and the
may be detected. sputa may be blood-stained for many
days.
Prognosis. — Except in the case of rupture of aneurism or of large
veins, haematemesis rarely proves fatal. In my experience death has fol-
388 DISEASES OF THE DIGESTIVE SYSTEM.
lowed more frequently in cases of cirrhosis and splenic enlargement than
in ulcer or cancer. In ulcer it is to be remembered that in the chronic
hgemorrhagic form the bleeding may recur for years. The treatment of
hgematemesis is considered under gastric ulcer.
YII. DISEASES OF THE INTESTINES.
I. DISEASES OF THE INTESTINES ASSOCIATED WITH
DIARRHOEA.
CATARRHAL ENTERITIS; DIARRHCEA.
In the classification of catarrhal enteritis the anatomical divisions of
the bowel have been too closely followed, and a duodenitis, jejunitis, ilei-
tis, typhlitis, colitis, and proctitis have been recognized ; whereas in a
majority of cases the entire intestinal tract, to a greater or lesser extent, is
involved, sometimes the small most intensely, sometimes the large bowel,
but during life it may be quite impossible to say which portion is specially
affected.
Etiology. — The causes maybe either primary or secondary. Among
the causes of primary catarrhal enteritis are : (a) Improper food, one of
the most frequent, especially in children, in whom it follows overeating,
or the ingestion of unripe fruit. In some individuals special articles of
diet will always produce a slight diarrhoea, which may not be due to a
catarrh of the mucosa, but to increased peristalsis induced by the offend-
ing material, (b) Various toxic substances. Many of the organic poi-
sons, such as those produced" in the decomposition of milk and articles of
food, excite the most intense intestinal catarrh. Certain inorganic sub-
stances, as arsenic and mercury, act in the same way. (c) Changes in the
weather. A fall in the temperature of from twenty to thirty degrees, par-
ticularly in the spring or autumn, may induce— how, it is difficult to say
—an acute diarrhoea. We speak of this as a catarrhal process, the result
of cold or of chill. On the other hand, the diarrhoeal diseases of children
are associated in a very special way with the excessive heat of summer
months, (d) Changes in the constitution of the intestinal secretions.
We know too little about the snccus enterictis to be able to speak of influ-
ences induced by change in its quantity or quality. It has long been held
that an increase in the amount of bile poured into the bowel might excite a
diarrhoea ; hence the term bilious diarrha^a, so frequently used by the older
writers. Possibly there are conditions in which an excessive amount of bile
is poured into the intestine, increasing the peristalsis, and hurrying on the
contents; but the opposite state, a scanty secretion, by favoring the natural
fermentative processes, much more commonly causes an intestinal catarrh.
Absence of the pancreatic secretion from the intestine has been associated
DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRIKEA. 389
in certain cases with a fatty diarrliooa. (e) Nervous influences. It is by
no means clear how mental states act upon the bowels^ and yet it is an old
and trustworthy observation which every-day experience confirms that the
mental state may profoundly affect t]\B intestinal canal. These influences
should not properly be considered under catarrhal processes, as they result
simply from increased peristalsis or increased secretion, and are usually de-
scribed under the heading 7iervous diarrhcea. In children it frequently
follows fright. It is common, too, in adults as a result of emotional dis-
turbances. Canstatt mentions a surgeon who always before an important
operation had watery diarrhoea. In hysterical women it is seen as an occa-
sional occurrence, due to transient excitement, or as a chronic, protracted
diarrhoea, which may last for months or even years.
Among the secondary causes of intestinal catarrh may be mentioned :
{a) Infectious diseases. Dysentery, cholera, typhoid fever, pyaemia,
septicaemia, tuberculosis, and pneumonia are occasionally associated with
intestinal catarrh. In dysentery and typhoid fever the ulceration is in
part responsible for the catarrhal condition, but in cholera it is probably a
direct influence of the bacilli or of the toxic materials produced by them.
{b) The extension of inflammatory processes from adjacent parts. Thus,
in peritonitis, catarrhal swelling and increased secretion are always present
in the mucosa. In cases of invagination, hernia, tuberculous or cancerous
ulceration, catarrhal processes are common, (c) Circulatory disturbances
cause a catarrhal enteritis/ usually of a very chronic character. This is
common in diseases of the liver, such as cirrhosis, and in chronic affections
of the heart and lungs — all conditions, in fact, which produce engorge-
ment of the terminal branches of the portal vessels, {d) In the cachectic
conditions met with in cancer, profound anaemia, Addison's disease, and
Bright's disease intestinal catarrh may develop, and may terminate life.
Morbid Anatomy. — Changes in the mucous membrane are not
always visible, and in cases in which, during life, the symptoms of intes-
tinal catarrh have been marked, neither redness, swelling, nor increased
secretion — the three signs usually laid down as characteristic of catarrhal
inflammation— may be present post mortem. It is rare to see the mucous
membrane injected ; more commonly it is pale and covered with mucus.
In the upper part of the small intestine the tips of the valvula3 conniventes
may be deeply injected. Even in extreme grades of portal obstruction
intense hyperaemia is not often seen. The entire mucosa may be softened
and infiltrated, the lining epithelium swollen, or even shed, and appearing
as large flakes among the intestinal contents. This is, no doubt, a post-
mortem change. The lymph follicles are almost always swollen, particu-
larly in children. The Peyer's patches may be prominent and the solitary
follicles in the large and small bowel may stand out with distinctness and
present in the centres little erosions, the so-called follicular ulcers. This
may be a striking feature in the intestine in all forms of catarrhal enteri-
tis in children, quite irrespective of the intensity of the diarrhoea.
300 DISEASES OP THE DIGESTIVE SYSTEM.
When the process is more chronic the mucosa is firmer, in some in-
stances thickened, in otliers distinctly thinned, and the villi and follicles
present a slaty pigmentation.
Symptoms. — Acute and chronic forms may be recognized. The im-
portant syni})tom of both is diarrhoea, Avhich, in the majority of instances,
is the sole indication of this condition. It is not to be supposed that diar-
rhoea is invariably caused by, or associated with, catarrhal enteritis, as it
may be produced by nervous and other influences. It is probable that
catarrh of the jejunum may exist without any diarrhoea ; indeed, it is a
very common circumstance to find post mortem a catarrhal state of the
small bowel in persons who have not had diarrhoea during life. The
stools vary extremely in character. The color depends upon the amount
of bile with which they are mixed, and they may be of a dark or blackish
brown, or of a light-yellow, or even of a grayish-white tint. The consist-
ence is usually very thin and watery, but in some instances the stools are
pultaceous like thin gruel. Portions of undigested food can often be seen
(lienteric diarrhoea), and flakes of yellowish-brown mucus. Microscopic-
ally there are innumerable micro-organisms, epithelium and mucous cells,
crystals of phosphate of lime, oxalate of lime, and occasionally cholesterin
and Charcot's crystals.
Pain in the abdomen is usually present in the acute catarrhal enteritis,
particularly wdien due to food. It is of a colicky character, and when the
colon is involved there may be tenesmus. More or less tympanites exists,
and there are gurgling noises or borborygmi, due to the rapid passage of
fluid and gas from one part to another. In the very acute attacks there
may be vomiting. Fever is not, as a rule, present, but there may be a
slight elevation of one or two degrees. The appetite is lost, there is in-
tense thirst, and the tongue is dry and coated. In very acute cases, when
the quantity of fluid lost is great and the pain excessive, there may be
collapse symptoms. The number of evacuations varies from four or five
to twenty or more in the course of the day. The attack lasts for two or
three days, or may be prolonged for a week or ten days.
Chronic catarrh of the bowels may follow the acute form, or may de-
velop gradually as an independent affection or as a sequence of obstruc-
tion in the portal circulation. It is characterized by diarrh(x?a, with or
without colic. The dejections vary ; when the small bowel is chiefly in-
volved the diarrhoea is of a lienteric character, and wlicn the colon is
affected the stools are thin and mixed with much mucus. A special
form of mucous diarrhoea will be subsequently described. The general
nutrition of the patient in these chronic cases is greatly disturbed ; there
may be much loss of flesh and great pallor. The patients are inclined to
suffer from low spirits, or hypochoiulriasis may develop.
Diagnosis. — It is important, in the first place, to determine, if pos-
sible, whether the large or small bowel is chiefly affected. In catarrh of
the small bowel the diarrhoea is less marked, the pains are of a colicky
DISEASES OF THE INTESTINES ASSOCIATED WITH DIARIIIKEA. 391
cliarjKitor, borhoryi^mi are not so froqnont, the foeccR iiRiially contain por-
tions of food, and arc more ycjlowish-grccn or grayisli-yollow and floo
culent and do not contain mncli mucus. When the large intestine is at
fault there may be no pain whatever, as in the catarrh of the large intes-
tine associated with tuberculosis and Bright's disease. Wlien present, the
pains are most intense and, if the lower portion of the bowel is involved,
there may be marked tenesmus. The stools have a uniform soupy con-
sistence, grayish in color and granular throughout, with here and there
flakes of mucus, or they may contain very large quantities of mucus.
There are no positive symptoms by which the diagnosis of duodenitis
can be made. It is usually associated with acute gastritis and, if the pro-
cess extends into the bile-duct, with jaundice, l^either jejunitis nor
ileitis can be separated from general intestinal catarrh.
ENTERITIS IN CHILDREN.
We may recognize three forms : (1) The acute dyspeptic diarrhoea ; (2)
cholera infantum ; and (3) acute entero-colitis.
General Etiology of the Diarrhoeas of Children. — The dis-
ease is most frequent in artificially fed children, and the greatest number
of cases occur between the ages of six and eighteen months. A popular
and well-founded belief ascribes special danger to the second summer of
the infant. Infantile diarrhoea is very prevalent among the poorer classes
in the large cities. It attacks, however, children with the most favorable
surroundings. Two factors influence the disease, diet and temperature.
An immense majority of all fatal cases are artificially fed. Of 1,943 fatal
cases in Holt's statistics, only three per cent were exclusively breast fed.
Among the poor the bowel complaint in children begins with the artificial
feeding. The relation of temperature to the prevalence of diarrhoeal dis-
eases in children has long been recognized. The mortality curve begins
to rise in May, increases in June, reaches the maximum in July, and grad-
ually sinks through August and September. The maximum corresponds
closely with the highest mean temperature ; yet we cannot regard the heat
itself as the direct agent, but only one of several factors. Thus the mean
temperature of June is only four or five degrees lower than that of July,
and yet the mortality is not more than one third. >Seibert, who has care-
fully analyzed the mortality and the temperature, month by month, in
Xew York, for ten years, fails to find a constant relation between the
degree of heat and the number of cases of diarrhoea. Neither barometric
pressure nor humidity appears to have any influence.
Relation of Bacteria. — The healthy faeces of sucklings contain a
numljcr of Ijactoria and micrococci, tlie most important of which are the
bacterium lactis aerofjeiies and the hacterium coll commune. The former
is only present in the intestine after a milk diet, the milk sugar appear-
ing to furnish the materials necessary for its growth. It occurs more
392 DISEASES OF THE DIGESTIVE SYSTEM.
in the npper portion of the bowel, and in this region excites the fer-
mentative processes in the milk. The hacterium coli comminie is found
more abundantly in the lower portion of the small intestine and in ttie
colon, and excites fermentative changes which are probably associated with
certain phases of digestion. The observations of Escherich show the re-
markable simplicity of this bacterial vegetation in the healthy faeces of
milk-fed children, as these two alone develop and are constant. In infan-
tile diarrhoea the number of bacteria which may be isolated from the stools
is remarkable. Booker has discriminated forty varieties, the greatest num-
ber of which were found in the cases of cholera infantum. The two con-
stant forms noted above do not disappear in the diarrhoeal stools. No
forms have been found to bear a constant or specific relation to the diar-
rhoeal faeces, such as the two above mentioned do to the healthy milk
faeces. The bacteria of ih.Q proteiis group are most frequent, and possess
pathogenic properties. All the varieties develop and produce important
changes in the milk, which have been dealt with very fully by Booker in
his studies. This author concludes that in the diarrhoea of infants " not
one specific kind, but many different kinds of bacteria are concerned,
and that their action is manifested more in the alteration of the food and
intestinal contents and in the production of injurious products than in a
direct irritation upon the intestinal wall." "With these agree the conclu-
sions of Jeffries and Baginsky regarding cholera infantum.
Morbid Anatomy. — We find most frequently a catarrhal swelling
of the mucosa of both small and large bowel with enlargement of the
lymph follicles. In more chronic cases the latter show small erosions or
follicular ulcers ; more rarely there is croupous enteritis affecting the
lower part of the ileum and the colon. The changes in the other organs
are neither numerous nor characteristic. Broncho-pneumonia occurs in
many cases. The spleen may be swollen. Brain lesions are rare ; the
membranes and substance are often ana?mic, but meningitis or thrombosis
is very uncommon.
Clinical Forms. — Acute Dyspeptic Diarrhoea. — The child may ap-
pear in its usual health, but has an increase in the number of stools, with-
out fever or special disturbance except slight restlessness at night. After
persisting for a day or two the stools become more frequent and contain
undigested food and curds, and are very offensive. In other cases the dis-
ease sets in abruptly with vomiting, griping pains, and fever, which may rise
rapidly and reach 104° or 105°. There may be convulsions at the outset.
The abdomen is sensitive, and the child lies with the legs drawn up. The
stools consist of grayish or greenish-yellow foBces mixed with gas, curds,
and portions of food. In children over two years of age such attacks not
infrequently follow eating freely of unripe fruit or the drinking of milk
which has been tainted. With judicious treatment the children improve
in a few days ; but relapses are not uncommon, and in the hot weather
the attack may be the starting point of a severe entero-colitis. In a de-
DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHfEA. 393
bilitated cliild a, mild attack may prove fatal. This dyspeptic diarrlicea is
distinguished sharply from cholera infantum by the character of the
stools, which never have a watery, serous character. In many instances
this form precedes the onset of the specific fevers, particularly during the
hot weather.
Cholera Infantum. — This is the counterpart in the infant of the so-
called choleraic diarrha3a in the adult, and in their clinical aspects these
two forms are identical. It is by no means so common as the ordinary
dyspeptic diarrhoea of children, and, according to Holt, occurs only in
two or three per cent of the cases of summer diarrhoea. It prevails in
the hot weather and in children artificially fed or who have had pre-
viously some slight dyspeptic derangement. It is characterized by vomit-
ing, uncontrollable diarrhoea, and collapse. The disease sets in with
vomiting, which is incessant and is excited by any attempt to take food or
drink. The stools are profuse and frequent ; at first faecal in character,
brown or yellow in color, and finally thin, serous, and watery. The stools
first passed are very offensive ; subsequently they are odorless. The thin,
serous stools are alkaline. There is fever, but the axillary temperature
may register three or more degrees below that of the rectum. From the
outset there is marked prostration ; the eyes are sunken, the features
pinched, the fontanelle depressed, and the skin has a peculiar ashy pallor.
At first restless and excited, the child subsequently becomes heavy, dull,
and listless. The tongue is coated at the onset, but subsequently becomes
red and dry. As in all choleraic conditions, the thirst is insatiable ; the
pulse is rapid and feeble, and toward the end becomes irregular and im-
perceptible. Death may occur within twenty-four hours, with symptoms
of collapse and great elevation of the internal temperature. Before the
end the diarrhoea and vomiting may cease. In other instances the intense
symptoms subside, but the child remains torpid and semi-comatose with
fingers clutched, and there may be convulsions. The head may be retract-
ed and the respirations interrupted, irregular, and of the Cheyne-Stokes
type. The child may remain in this condition for some days without any
signs of improvement. It was to this group of symptoms in infantile
diarrhcea that Marshall-IIall gave the term " hydrencephaloid " or spuri-
ous hydrocephalus. As a rule, no changes in the brain or other organs
are found, and the condition is no doubt caused by the toxic agents
absorbed from the intestine. A remarkable condition of sclerema is de-
scribed as a sequel of cholera infantum. The skin and subcutaneous tis-
sues become hard and firm and the appearance has been compared to that
of a half-frozen cadaver.
No constant organism has been found in these cases. Baginsky con-
siders the disease the result of the action on the system of the poisonous
products of decomposition encouraged by the various bacteria present — a
fdulniss disease. The clinical picture is that produced by an acute bac-
terial infection, as in Asiatic cliolera.
20
394 DISEASES OF THE DIGESTIVE SYSTEM.
The diagnosis is readily made. There is no other intestinal affection
in children for which it can be mistaken. The constant vomiting, the
frequent watery discharges, the collapse symptoms, and the elevated tem-
perature make an unmistakable clinical picture. The outlook in the ma-
jority of cases is bad, particularly in children artificially fed. Hyperpy-
rexia, extreme collapse, and incessant vomiting are the most serious symp-
toms.
Acute Entero-colitis. — In this form the ileum and colon are most
affected, chiefly in the lymph follicles, hence the term follicular enteritis
or follicular dysentery. It occurs most frequently in warm weather, in
artificially fed children ; but it may set in at any season of the year, and
is the form of enteritis most common as a secondary complication in the
specific fevers of childhood.
The attack may follow the ordinary dyspeptic diarrhoea. The tem-
perature increases, the stools change in character and contain traces of
blood and mucus, the former usually only in streaks. The faeces are
passed without any pain. The abdomen is distended and tender along
the line of the colon. Vomiting may be present at the outset, but is not a
characteristic feature, as in cholera infantum. The diarrhoea may be
gradually checked and convalescence is established in two or three weeks ;
in other instances the disease becomes subacute, the fever subsides, but the
diarrhoea persists and the general health of the child rapidly deteriorates.
The case may drag on for five or six weeks, when improvement gradually
occurs or the child is carried off by a severe intercurrent attack. In a
third form of acute entero-colitis, in which anatomically the lesions are
those already mentioned — namely, an intense follicular inflammation — the
symptoms are of a more severe character, and the affection is sometimes
spoken of as acute dysentery. It attacks children up to the third or
fourth year or even older. The onset is sudden, with high fever, vomit-
ing, frequent stools, which at first contain remnants of food and faeces
and subsequently much mucus and some blood. There is incessant pain,
which may be more severe than in any intestinal affection of childhood.
The prostration is very great and the fatal termination may occur within
forty-eight hours. More commonly the case lasts for a week or longer.
In two cases of this sort, in one of which death occurred in forty-eight
and in the other in sixty-four hours, the anatomical characters were those
of the most acute follicular enteritis, characterized by great swelling of
the lymph follicles, some of which already presented necrotic foci.
The Coellac Affection. — Under this heading Cee has described an intes-
tinal disorder, most commonly met with in children between the ages of
one and five, characterized by the occurrence of pale, loose stools, not
unlike gruel or oatmeal porridge. They are bulky, not watery, yeasty,
frothy, and extremely offensive. The affection has received various names,
such as diarrhma alba or diarrhma chylosa. It is not associated with
tuberculosis or other hereditary disease. It begins insidiously and there
DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRIKEA. 395
are progressive wasting, weciknesa, and pallor. The belly becomes doughy
and inelastic. There is often flatulency. Fever is usually absent. The
disease is lingering and a fatal termination is common. So far nothing is
known of the pathology of the disease. Ulceration of the intestines has
been met with, but it is not constant. This affection resembles somewhat
the disease in adults known as the liill diarrlioea^ or the white flux of
India; but certain of these tropical diarrhooas are, as will be mentioned,
associated with the presence of the anchylostoma.
DIPHTHERITIC OR CROUPOUS ENTERITIS.
There are many conditions in which an intense croupous or diph-
theritic inflammation of the mucosa of the small and large intestines
occurs. It is met with most frequently, {a) as a secondary process in the
infectious diseases — pneumonia, pyaemia in its various forms, and typhoid
fever; {h) as a terminal process in many chronic affections, such as
Bright's disease, cirrhosis of the liver, or cancer ; and (c) as an effect of
certain poisons — mercury, lead, and arsenic.
The disease presents three different anatomical pictures. In one group
of cases the mucosa presents on the top of the folds a thin grayish-yellow
diphtheritic exudate situated upon a deeply congested base. In some
cases all grades may be seen between the thinnest film of superficial
necrosis and involvement of the entire thickness of the mucosa. In the
colon similar transversely arranged areas of necrosis are seen situated
upon hypaeramic patches, and it may be here much more extensive and
involve a large portion of the membrane. There may be most extensive
inflammation without any involvement of the solitary follicles of the large
or small bowel.
In a second group of cases the membrane has rather a croupous
character. It is grayish white in color, more flake-like and extensive,
limited, perhaps, to the caecum or to a portion of the colon ; thus, in
several cases of pneumonia I found this flaky adherent false membrane,
in one instance forming patches 1 to 2 cm. in diameter, which were not
unlike in form to rupia crusts.
In a third group the affection is really a follicular enteritis, involving
the solitary glands, which are swollen and capped with an area of diph-
theritic necrosis or are in a state of suppuration. Follicular ulcers are
common in this form. The disease may run its course without any
symptoms, and the condition is unexpectedly met with post mortem. In
other instances there are diarrhoea, pain, but not often tenesmus or the
passage of blood-stained mucus. In the toxic cases the intestinal symp-
toms may be very marked, but in the terminal colitis of the fevers and of
constitutional aff'ections the symptoms are often trifling.
396 DISEASES OF THE DIGESTIVE SYSTEM.
PHLEGMONOUS ENTERITIS.
As an independent affection this is excessively rare, even less frequent
than its counterpart in the stomach. It is seen occasionally in connection
with intussusception, strangulated hernia, and chronic obstruction. Apart
from these conditions it occurs most frequently in the duodenum, and
leads to suppuration in the submucosa and abscess formation. Except
when associated with hernia or intussusception the affection cannot be
diagnosed. The symptoms usually resemble those of peritonitis.
MUCOUS COLITIS.
This affection is known by various names, such as memhra7ioiis en-
teritis^ tubular diarrlicea^ and mucous colic. It is a remarkable disease,
to which much attention has been paid for several centuries. An exhaust-
ive description of it is given by Woodward, in Vol. II of the Medical
and Surgical Keports of the Civil War. It is an affection of the large
bowel, characterized by the production of a very tenacious adherent mucus,
which may be passed in long strings or as a continuous, tubular mem-
brane. I have twice had opportunities of seeing this membrane 171 situ,
closely adherent to the mucosa of the colon, but capable of separation
without any lesion of the surface. Judging from the statement of Eng-
lish authors as to its rarity, it would appear to be a more frequent disease
in this country. According to W. A. Edwards, 80 per cent of the re-
corded adult cases have been in women. It occurs occasionally in children.
Of 111 cases six were under the age of ten. The cases are almost invari-
ably seen in nervous or hysterical women or in men with neurasthenia.
All grades of the affection occur, from the passage of a slimy mucus, like
frog-spawn, to large tubular casts a foot or more in length. Microscopi-
cally the casts are, as shown by Sir Andrew Clark, not fibrinous, but
mucoid, and even the firmest consist of dense, opaque, transformed mucus.
It is due to a derangement of the mucous glands of the colon, the nature
of which is quite unknown.
Symptoms. — The disease persists for years, varying extremely from
time to time, and is characterized by paroxysms of pain in the abdomen,
tenderness, occasionally tenesmus, and the passage of flakes or long strings
of mucus, sometimes of definite casts of the bowel. The attacks last for
a day or, in some instances, for ten days or two weeks. Mental emotions
and worry of any sort seem particularly apt to bring on an attack. Occa-
sionally errors in diet *or dyspepsia precede an outbreak. Membranes are
not passed with every paroxysm, even when the pains and cramps are severe.
There are instances in which the morphia habit has been contracted on
account of the severity of the pain. There may be marked nervous
symptoms, and authors mention hysterical outbreaks, hypochondriasis,
and melancholia^
DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRIICEA. 397
The diagnosis is rarely doubtful, but it is important not to mistake
the membranes for other substances ; thus, the external cuticle of aspara-
gus and undigested portions of meat or sausage-skins sometimes assume
forms not unlike mucous casts, but the microscopical examination will
quickly differentiate them.
ULCERATIVE ENTERITIS.
In addition to the specific ulcers of tuberculosis, syphilis, and typhoid
fever, the following forms of ulceration occur in the bowels :
(«) Follicular Ulceration. — As previously mentioned, this is met with
very commonly in the diarrhoeal diseases of children, and also in the sec-
ondary or terminal inflammations in many fevers and constitutional disor-
ders. The ulcers are small, punched out, with sharply cut edges, and
they are usually limited to the follicles. With this form may be placed
the catarrhal ulcers of some writers.
{b) Stercoral Ulcers, which occur in long-standing cases of constipa-
tion. Very remarkable indeed are the cases in which the sacculi of the
colon become filled with roundea small scybala, some of which produce
distinct ulcers in the mucous membrane. The faecal masses may have
lime salts deposited in them, and thus form little enteroliths.
(c) Simple Ulcerative Colitis. — This affection, which clinically is char-
acterized by diarrhoea, is often regarded wrongly as a form of dysentery.
It is not a very uncommon affection, and is most frequently met with in
men above the middle period of life. The ulceration may be very exten-
sive, so that a large proportion of the mucosa is removed. The lumen of
the colon is sometimes greatly increased, and the muscular walls hyper-
trophied. There are instances in which the bowel is contracted. Fre-
quently the remnants of the mucosa are very dark, even black, and there
may be polypoid outgrowths between the ulcers.
These cases rarely come under observation at the outset, and it is diffi-
cult to speak of the mode of origin. They are characterized by diarrhcea
of a lienteric rather than of a dysenteric character. There is never blood
or pus in the stools. Constipation may alternate with the diarrhoea.
There is usually great impairment of nutrition, and the patients get weak
and sallow. Perforation occasionally occurs.
The disease may prove fatal, or it may pass on and become chronic.
The affection was not very infrequent at the Philadelphia Hospital, and
though the disease bears some resemblance to dysentery, it is to be sepa-
rated from it. Some of the cases which we have learned to recognize as
amoibic dysentery resemble this form very closely. An excellent descrip-
tion of it is given by Hale White.*
{d) Ulceration from External Perforation. — This may result from the
* Guy's Hospital Reports, 1888.
398 DISEASES OF THE DIGESTIVE SYSTEM.
erosion of new growths or, more commonly, from localized peritonitis with
abscess formation and perforation of the bowel. This is met with most fre-
quently in tuberculous peritonitis, but it may occur in the abscess which
follows perforation of the appendix or suppurative or gangrenous pan-
creatitis. Fatal haemorrhage may result from the perforation.
(e) Cancerous Ulcers. — In very rare instances of multiple cancer or
sarcoma the submucous nodules break down and ulcerate. In one case
the ileum contained eight or ten sarcomatous ulcers secondary to an ex-
tensive sarcoma in the neighborhood of the shoulder-joint.
(/) Occasionally a solitary ulcer is met with in the caecum or colon,
which may lead to perforation. Two instances of ulcer of the caecum,
both with perforation, have come under my observation, and in one
instance a simple ulcer of the colon perforated and led to fatal perito-
nitis.
Diagnosis of Intestinal Ulcers. — As a rule, diarrhoea is present
in all cases, but exceptionally there may be extensive ulceration, particu-
larly in the small bowel, without diarrhoea. Very limited ulceration in
the colon may be associated with frequent stools. Tlie character of the
dejections is of great importance. Pus, shreds of tissue, and blood are
the most valuable indications. Pus occurs most frequently in connection
with ulcers in the large intestine, but when the bowel alone is involved
the amount is rarely great, and the passage of any quantity of pure pus is
an indication that it has come from without, most commonly from the
rupture of a pericaecal abscess, or in women an abscess of the broad liga-
ment. Pus may also be present in cancer of the bowel, or it may be due
to local disease in the rectum. A purulent mucus may be present in the
stools in cases of ulcer, but it has not the same diagnostic value. The
swollen, sago-like masses of mucus which are believed by some to indicate
follicular ulceration are met with also in mucous colitis. Haemorrhage is
an important and valuable symptom of ulcer of the bowel, particularly if
profuse. It occurs under so many conditions that taken alone it may
not be specially significant, but with other coexisting circumstances it
may be the most important indication of all.
Fragments of tissue are occasionally found in the stools in ulcer, par-
ticularly in the extensive and rapid sloughing in dysenteric processes.
Definite portions of mucosa, shreds of connective tissue, and even bits of
the muscular coat may be found. Pain occurs in many cases, either of a
diifuse, colicky character, or sometimes, in the ulcer of the colon, very
limited and well defined.
Perforation is an accident liable to happen when tlie ulcer extends
deeply. In the small bowel it leads to a localized or general peritonitis.
In the large intestine, too, a fatal peritonitis may result, or if perforation
takes place in the posterior wall of the ascending or descending colon,
the production of a large abscess cavity in the retro-peritonaeum. In a
case at the University Hospital, Philadelphia, there was a perforation at
DISEASES OP THE INTESTLVES ASSOCIATED WITH DIARRHOEA. 399
the splenic flexure of the colon with an abscess containing air and pus
— a condition of subphrenic pyo-pneumothorax.
Treatment of the Previous Conditions.
(a) Acute Dyspeptic Diarrhoea. — All solid food sliould be witliheld.
If vomiting is present ice may be given, and small quantities of milk and
soda water may be taken. If the attack has followed the eating of large
quantities of undigestible material, castor oil or calomel is advisable, but
is not necessary if the patient has been freely purged. If the pain is se-
vere, twenty drops of laudanum and a drachm of spirits of chloroform
may be given, or, if the colic is very intense, a hypodermic of a quarter of
a grain of morphia. It is not well to check the diarrhoea unless it is pro-
fuse, as it usually stops spontaneously within forty-eight hours. If per-
sistent, the aromatic chalk powder or large doses of bismuth (thirty to
forty grains) may be given. A small enema of starch (two ounces) with
twenty drops of laudanum, every six hours, is a most valuable remedy.
(b) Chronic Diarrhoea, including chronic catarrh and ulcerative enter-
itis. It is important, in the first place, to ascertain, if possible, the cause
and whether ulceration is present or not. So much in treatment depends
upon the careful examination of the stools — as to the amount of mucus,
the presence of pus, the occurrence of parasites, and, above all, the state of
digestion of the food — that the practitioner should pay special attention
to them. Many cases simply require rest in bed and a restricted diet.
Chronic diarrhoea of many months' or even of several years' duration may
be sometimes cured by strict confinement to bed and a diet of boiled milk
and albumen water.
In that form in which immediately after eating there is a tendency to
loose evacuations it is usually found that some one article of diet is at
fault. The patient should rest for an hour or more after meals. Some-
times this alone is sufficient to prevent the occurrence of the diarrhoea.
In those forms which depend upon abnormal conditions in the small in-
testine, either too rapid peristalsis or faulty fermentative processes, bis-
muth is indicated. It must be given in large doses— from half a drachm
to a drachm three times a day. The smaller doses are of little use.
Naphthalin preparations here do much good, given in doses of from ten
to fifteen grains (in capsule) four or five times a day. Larger doses may
be needed. Salol and the salicylate of bismuth may be tried.
An extremely obstinate and intractable form is the diarrhoea of hyster-
ical women. A systematic rest cure will be found most advantageous, and
if a milk diet is not well borne the patient may be fed exclusively on egg
albumen. The condition seems to be associated in some cases with in-
creased peristalsis, and in such the bromides may do good, or preparations
of opium may be necessary. There are instances which prove most obsti-
nate and resist all forms of treatment, and the patient may be greatly
reduced. A change of air and surroundings may do more than medicines.
In a large group of the chronic diarrhoeas the mischief is seated in the
400 DISEASES OF THE DIGESTIVE SYSTEM.
colon and is due to ulceration. Medicines by the mouth are here of little
value. The stools should be carefully watched and a diet arranged which
shall leave the smallest possible residue. Boiled or peptonized milk may
be given, but the stools should be examined to see whether there is an
excess of food or of curds. Meat is, as a rule, badly borne in these cases.
The diarrhoea is best treated by enemata. The starch and laudanum
should be tried, but when ulceration is present it is better to use astringent
injections. From two to four pints of warm water containing from half a
drachm to a drachm of nitrate of silver may be used. In the chronic
diarrhcea which follows dysentery this is particularly advantageous. In
giving large injections the patient should be in the dorsal position, with
the hips elevated, and it is best to allow the injection to flow in gradually
from a siphon bag. In this way the entire colon can be irrigated and the
patient can retain the injection for some time. The silver injections may
be very painful, but they are invaluable in all forms of ulcerative colitis.
Acetate of lead, boracic acid, sulphate of copper, sulphate of zinc, and
salicylic acid may be used in one per cent solutions.
In mucous colitis no benefit can be expected from remedies adminis-
tered by the mouth. The topical applications should be made to the
mucous membrane of the colon by the enemata just mentioned, and the
general nervous condition should receive appropriate treatment.
In the intense forms of choleraic diarrhoea in adults associated with
constant vomiting and frequent watery discharges the patient should be
given at once a hypodermic of a quarter of a grain of morphia, which
should be repeated in an hour if the pains return or the purging persists.
This gives prompt relief, and is often the only medicine needed in the
attack. The patient should be given stimulants, and, when the vomiting
is allayed by suitable remedies, small quantities of milk and lime water.
(c) The Diarrhoea of (jlai[dvQJi.—IIijgie7iic management is of the first
importance. The eifect of a change from the hot, stifling atmosphere of
a town to the mountains or the sea is often seen at once in a reduction
in the number of stools and a rapid improvement in the physical condi-
tion. Even in cities much may be done by sending the child into the
parks or for daily excursions on the water. However extreme the condi-
tion, fresh air is indicated. The child should not be too thickly clad.
Many mothers, even in the warm weather, clothe their children too heavily.
Bathing is of value in infantile diarrhoea, and when the fever rises above
102-5° the child should be placed in a warm bath, the temperature of
which may be gradually reduced, or the child is kept in the bath for
twenty minutes, by which time the water is sufficiently cooled. Much
relief is obtained by the application of ice-cold cloths or of the ice-cap to
the head. Irrigation of the colon with ice-cold water is sometimes favor-
able, but it has not the advantage of the general bath, the beneficial effect
of which is seen, not only in the reduction of the temperature, but in a
general stimulation of the nervous system of the child.
DISEASES OP THE INTESTINES ASSOCIATED WITH DIARRIICEA. 40I
Dietetic Treatment. — In the case of a hand-fed child it is important,
if possible, to get a wet-nurse. While fever is present, digestion is sure
to be much disturbed, and the amount of food should be restricted. If
water or barley water be given the child will not feel the deprivation of
food so much. When the vomiting is incessant it is much better not to
attempt to give milk or other articles of food, but let the child take the
water whenever it will.
In the dyspeptic diarrhoeas of infants, practically the whole treatment
is a matter of artificial feeding, and there is no subject in medicine on
which it is more difficult to lay down satisfactory rules. No doubt within
a few years the study of the bacterial processes going on in the intestines
of the child will give us most important suggestions. From his observa-
tions Escherich lays down the following rules, recognizing two well-
defined forms of intestinal fermentation — the acid and the alkaline : If
there is much decomposition, with foul, offensive stools, the albuminous
articles should be withheld from the diet and the carbohydrates given,
such as dextrin foods, sugar, and milk, which, on account of its sugar,
ranks with the carbohydrates. If there is acid fermentation, with sour
but not fetid stools, an albuminous diet is given, such as broths and Qgg
albumen. It is, however, by no means certain whether the reaction of the
stools, upon which this author relies, is a sufficient test of the nature of
the intestinal fermentation. In the dyspeptic diarrhoeas of artificially fed
infants it is best, as a rule, to withhold milk and to feed the child, for the
time at least, on Qgg albumen, broths, and beef juices. To prepare the
Qgg albumen, the whites of two or three eggs may be stirred in a pint of
water and a teaspoonful of brandy and a little salt mixed with it. The
child will usually take this freely, and it is both stimulating and nourish-
ing. It is sometimes remarkable with what rapidity a child which has
been fed on artificial food and milk will pick up and improve on this diet
alone. Beef -juice is obtained by pressing with a lemon-squeezer fresh
steak, previously minced and either uncooked or slightly broiled. This
may be given alternately with the egg albumen or it may be given alone.
Mutton or chicken broth will be found equally serviceable, but it is pre-
pared with greater difficulty and contains more fat. In the preparation, a
pound of mutton, chicken, or beef, carefully freed from fat, is minced and
placed in a pint of cold water and allowed to stand in a glass jar on ice
for three or four hours. It should then be cooked over a slow fire for at
least three hours, then strained, allowed to cool, the fat skimmed off, suf-
ficient salt added, and it may then be given either warm or cold. These
naturally prepared albumen foods are very much to be preferred to the
various artificial substances. There is no form of nourishment so readily
assimilated and apt to cause so little disturbance as Qgg albumen or the
simple beef juices. The child should be fed every two hours, and in the
intervals water may be freely given. It cannot be expected that, with
the digestion seriously impaired, as much food can be taken as in health.
402 DISEASES OF THE DIGESTIVE SYSTEM.
and in many instances we see the diarrhoea aggravated by persistent over-
feeding. AVlien the child's stomach is quieted and the diarrhcea checked
there may be a gradual return to the milk diet. The milk should be ster-
ilized, and in institutions and in cities this simple prophylactic measure is
of the very first importance and is readily carried out by means of the Ar-
nold steam sterilizer. The milk should be at first freely diluted — four
parts of water to one of milk, which is perhaps the preferable way — or it
may be peptonized. The stools should be examined daily, as important
indications may be obtained from them. Milk-whey and forms of fer-
mented milk are sometimes useful and may be employed when the stom-
ach is very irritable. These general directions as to food also hold good
in cholera infantum.
Medicinal Treatment. — The first indication in the dyspeptic diarrhoea
of children is to get rid of the decomposing matter in the stomach and
intestines. The diarrhoea and vomiting partially effect this, but it may
be more thoroughly accomplished, so far as the stomach is concerned, by
irrigation. It may seem a harsh procedure in the case of young infants,
but in reality, with a large-sized soft-rubber catheter, it is practised with-
out any difficulty. By means of a funnel, lukewarm water is allowed
to pass in and out until it comes away quite clear. I can speak in the
very warmest manner of the good results obtained by this simple pro-
cedure in cases of the most obstinate gastro-intestinal catarrh in children.
In most cases the warm water is sufficient. In some hands this method
has probably been carried to excess, but that does not detract from its
great value in suitable cases. To remove the fermenting substances from
the intestines, doses of calomel or gray powder may be administered. The
castor oil is equally efficacious, but is more apt to be vomited. Irri-
gation of the large bowel is useful, and not only thoroughly removes
fermenting substances, but cleanses the mucosa. The child should be
placed on the back with the hips elevated. A flexible catheter is passed
for from six to eight inches and from a pint to two pints of water allowed
to flow in from a fountain syringe. A pint will thoroughly irrigate the
colon of a child of six months and a quart that of a child of two years.
The water may be lukewarm, but when there is high fever ice-cold water
may be used. In cases of entero-colitis there may be injections with
borax, a drachm to the pint, or dilute nitrate of silver, which may be
either given in large injections, as in the adult, or in injections of three or
four ounces with three grains of nitrate of silver to the ounce. These
often cause very great pain, and it is well in such cases to follow the silver
injection with irrigations of salt solution, a drachm to a pint.
We are still without a reliable intestinal antiseptic. Neither naphtha-
lin, salol, resorcin, the salicylates, nor mercury meets the indications. As
in the diarrhcpa of adults, bismuth in large doses is often very effective,
but practitioners arc in the habit of giving it in doses which are quite in-
sufficient. To be of any service it must be used in large doses, so that an
MISCELLANEOUS AFFECTIONS OF TIIF I50WKLS. 403
infant a year old will take as much as two drachms in the day. The gray
powder has long been a favorite in this condition and may be given in
half -grain doses every hour. It is perhaps preferable to calomel, which
may be used in small doses of from one tenth to one fourth of a grain
every hour at the onset of the trouble. The sodium salicylate (in doses
of two or three grains every two hours to a child a year old) has been
recommended.
In cholera infantum serious symptoms may develop with great
rapidity, and here the incessant vomiting and the frequent purging
render the administration of remedies extremely difficult. Irrigation
of the stomach and large bowel is of great service, and when the fever
is high ice- water injections may be used or a graduated bath. As in
the acute choleraic diarrhoea of adults, morphia hypodermically is the
remedy which gives greatest relief, and in the conditions of extreme
vomiting and purging, with restlessness and collapse symptoms, this
drug alone commands the situation. A child of one year may be given
from li-Q to -^Q of a grain, to be repeated in an hour, and again if not
better. When the vomiting is allayed, attempts may be made to give
gray powder in half -grain doses with -^ of Dover's powder. Starch ( 5 ij)
and laudanum (rriij-iij) injections, if retained, are soothing and benefi-
cial. The combination of bismuth with Dover's powder will also be found
beneficial. No attempt should be made to give food. Water may be
allowed freely, even when ejected at once by vomiting. Small doses of
brandy or champagne, frequently repeated and given cold, are sometimes
retained. When the collapse is extreme, hypodermic injections of one per
cent saline solution may be used as recommended in Asiatic cholera, and
hypodermic injections of ether and brandy may be tried. The convales-
cence requires very careful management, as many cases pass on into the
condition of entero-colitis. When the intense symptoms have subsided,
the food should be gradually given, beginning with teaspoonful doses of
egg albumen or beef -juice. It is best to withhold milk for several days,
and when used it should be at first completely peptonized or diluted with
gruel. A teaspoonful of raw, scraped meat three or four times a day is
often well borne.
II. MISCELLANEOUS AFFECTIONS OF THE BOWELS.
Dilatation of the Colon. — This may be general or localized to the sig-
moid ilex u re.
It occurs not infrequently as a transient condition, and in many cases
it has an important influence, inasmuch as the distention may be ex-
treme, pushing up the diaphragm and seriously impairing the action of
the heart and lungs. II. Fenwick has called attention to this as occasion-
ally a cause of sudden heart-failure.
40i DISEASES OP THE DIGESTIVE SYSTEM.
Dilatation of the sigmoid flexure occurs particularly when this portion
of the bowel is congenitally very long. In such cases the bowel may be
so distended that it occupies the greater part of the abdomen, pushing up
the liver and the diaphragm. An acute condition is sometimes caused by
a twist in the mesocolon.
There is a chronic form in which the gut reaches an enormous size.
The coats may be hypertrophied without evidence of any special organic
change in the mucosa. In a specimen w^hich I saw with W. E. Hughes,
in Philadelphia, the colon was enormously dilated and held fourteen pints
of water, and the sigmoid flexure was four inches in diameter. It was
removed from a boy, aged three, who had had obstinate constipation and
at the age of two an attack of entero-colitis. At one time he was nineteen
days without a passage ; on another occasion twenty-four. The abdo-
men was enormously distended, everywhere tympanitic. The hyper-
trophy of the bowel-wall was much greater toward the sigmoid flexure
than near the caecum. In the section on Constipation in Infants a
case is referred to in which the colon and sigmoid flexure appeared to be
dilated.
Infarction of the Bowel. — The mesenteric vessels are terminal arteries,
and when blocked by emboli or thrombi the condition of infarction fol-
lows in the territory supplied. Probably the occlusion of small vessels
does not produce any symptoms and the circulation may be re-established.
If the superior mesenteric artery is blocked a serious and fatal condition
follows. Three instances have come under my observation. In one, a
woman aged fifty-five was seized with nausea and vomiting, which per-
sisted for more than a week. There was pain in the abdomen, tympanites,
and toward the close the vomiting was incessant and faecal. The autopsy
showed great congestion, with swelling and infiltration of the jejunum
and ileum. The superior mesenteric artery was blocked at its orifice by a
firm thrombus. In the second case, a woman aged seventy-five was seized
with severe abdominal pain and frequent vomiting. At first there was
diarrhea ; subsequently the symptoms pointed to obstruction, with great
distention of the abdomen. The post-mortem showed the small bowel,
with the exception of the first foot of the jejunum and the last six inches
of the ileum, greatly distended and deeply infiltrated with blood. The
mesentery was also congested and infiltrated. The superior mesenteric
artery contained a firm brownish-yellow clot. There were many recent
warty vegetations on the mitral valve. In tlie tliird case, a man aged forty
was suddenly seized witli intense pain in the abdomen, became faint, fell
to the ground, and vomited. For a week he had persistent vomiting,
severe diarrhoea, tympanites, and great pain in the abdomen. The stools
were thin and at times blood-tinged. The autopsy showed an aneurism
involving the aorta at the diaphragm. The su})orior mesenteric artery,
half an incli from its origin on tlie sac, was blocked by a portion of the
iibrinous clot of the aneurism. In the horse, infarction of the intestine is
APPENDICITIS. 405
extremely common in connection with the verminous aneurisms of the
mesenteric arteries and is the usual cause of colic in this animal.
III. APPENDICITIS.
{Typhlitis and Perityphlitis).
This is one of the most important of intestinal affections. Unfortu-
nately, much confusion still exists about the forms of inflammation in
the caecal region. Thus there are recognized typhlitis^ inflammation of the
caecum itself ; perityplilitis^ inflammation of the peritonaeum covering the
caecum; paratyphlitis^ inflammation of the connective tissue behind the
caecum, or, more correctly, as the caecum is usually covered by a serous
membrane, of the connective tissue in the neighborhood of this part of
the bowel. The use of the last two terms should be altogether discarded,
as the cases are, with rare exceptions, due to disease of the appendix ver-
miformis, and not to affections of the caecum.
We have in the caecal region the following affections :
Typhlitis^ inflammation of the caecum proper — a doubtful and un-
certain malady, the pathology of which is unknown, but which clinically
is still recognized by authorities. A majority of the cases are unquestion-
ably due to appendix disease.
Appendicitis: (1) Catarrhal; (2) ulcerative; (3) perforative, with
the production of abscesses, which may be pericaecal, pelvic, intra-perito-
neal, perinephritic, or lumbar, depending on the situation of the vermi-
form process.
TYPHLITIS.
At present inflammation of any sort, accompanied by pain in the right
iliac fossa, is generally thought to be due to disease of the appendix ; and,
so far as post-mortem statistics indicate, an immense majority of all these
cases are due tp this cause. Clinically, however, authors still recognize
typhlitis (inflammation of the caecum), associated with lodgment of faeces
{typJditis stercoralis) The cases are met with in young persons, in boys
more commonly than in girls ; the subjects have usually been constipated,
or there have been errors in diet. The patient complains of pain in the
right iliac fossa ; there are constipation, nausea, sometimes vomiting ;
fever, if present, is usually slight, rarely rising above 101°. There is ful-
ness in the right iliac fossa, the decubitus is dorsal, and the right thigh
may be flexed. On pressure there is tenderness, and in many instances a
doughy, sausage-shaped tumor in the right flank. The attack lasts for
from three days to a week, the pain gradually subsides, the tumor mass
disappears, and recovery is complete.
The anatomical condition is unknown, and it is by no means certain
that these cases are in reality caecal. Many are probably due to dis-
406 DISEASES OF THE DIGESTIVE SYSTEM.
ease of the appendix, and even when the sausage-shaped, doughy tumor,
regarded as diagnostic of typhlitis stercoralis, is present, the cagcitis and
fffical retention may be secondary. The cases do well ; a great majority
of them terminate favorably, a point which, as Pepper remarks, is opposed
to the belief that they are all dependent upon appendix disease.
In the treatment of this condition an ice-bag should be placed over the
cffical region, large enemata given once or twice a day to empty the colon,
and opium given to allay the pain.
More serious disease of the caecum does occasionally occur, and there
are a few instances in which an ulcer perforates. The rarity of this, how-
ever, is shown by the fact that Fitz was only able to collect three cases.
Two instances have come under my observation in which perforation of
an ulcer in the caecum led to extensive pericaecal abscess.
APPENDICITIS.
The appendix vermiformis is extremely variable in position. It com-
monly lies behind the ileum with the tip pointing toward the spleen. It
is frequently turned up behind the caecum or it lies upon the psoas muscle
with its tip at the margin of the pelvis. It has, however, been found in
almost every region of the abdomen. Thus in my post-mortem notes it is
stated to have been found in close contact with the bladder ; adherent to
the ovary or broad ligament ; in the central portion of the abdomen, close
to the navel ; in contact with the gall-bladder ; passing out at right angles
and adherent to the sigmoid flexure to the left of the middle line of the
abdomen ; and in one case it passed with the caecum into the inguinal
canal, curved upon itself, re-entered the abdomen, and was adherent to the
wall of an abscess cavity just to the right of the promontory of the sacrum.
Foreign bodies rarely lodge in it. Only two instances have come under
my notice ; in one there were eight snipe shot and in the other five apple
pips. On the other hand, oval bodies resembling date stones are very
common. They consist of inspissated mucus and faeces, in which in time
lime salts are deposited, forming enteroliths.
Post-mortem examinations show that the appendix is very frequently
the seat of extensive disease, past or present, without the history of any
definite symptoms pointing to trouble in the caecal region. Among the
commonest of these conditions is obliteration, either total or partial.
When at the caecal end, the appendix may be enormously dilated, forming
a tumor the size of the thumb or as large as a sausage. In the cases of
obliteration the appendix may be free, more commonly it is adherent, and
there may be about it signs of old inflammation or even a small encapsu-
lated abscess, which has given no trouble.
Etiology. — Appendicitis is a disease of young persons. According
to Fitz's statistics, more than fifty per cent of the cases occur before the
twentieth year ; sixty per cent between the sixteenth and thirtieth years
APPENDICITIS. 407
(Einhorn). It has been met with as early as the seventh week, but it is
rarely seen prior to tlie third year. It is very much more common in
males than in females — eighty per cent, according to the tables of Fitz,
but in his personal experience in 72 cases males were only twice as fre-
quently affected as females. Contrary to the general experience, the
Munich figures (Einhorn) indicate a relatively greater number of women
attacked. The faecal concretions and foreign bodies already referred to
probably play the most important role in the etiology of the disease. In a
series of 152 cases the fascal masses were present in forty-seven per cent
and foreign bodies in twelve per cent. Matter stock, in 1G9 cases of per-
forative appendicitis, found the percentage to be fifty-three and twelve,
respectively. Typhoid fever and tuberculosis frequently induce ulceration
of the appendix, but not often perforation. Fitz suggests that some of
the cases of peritonitis which recover in typhoid fever are due to perfora-
tion of the appendix. Traumatism plays a very definite role, and in a
number of cases the symptoms have followed the lifting of a heavy weight,
or a fall or a blow. Constipation, overloading the stomach with indigest-
ible food, indiscretions in diet, are mentioned in many cases. The tend-
ency of the disease to recur is remarkable. Among 257 cases (Fitz) eleven
per cent had had previous attacks. In the recurring appendicitis no fac-
tor is of greater importance than overeating, and attacks may follow
directly upon the taking of large quantities of unsuitable food.
Morbid Anatomy. — For practical purposes we recognize a catarrh-
al and an ulcerative appendicitis. In catarrhal appendicitis the entire
tube is thickened, the peritoneal surface may be slightly injected, and
adhesions may have formed, so that there is a slight circumscribed peri-
tonitis. The lumen may be much contracted, particularly toward the
caecal end ; the mucosa is thickened, covered with a tenacious mucus ; and
very commonly faical concretions or small enteroliths are present. The
coats are thickened throughout, particularly the muscularis, and the entire
tube is firm and stiff. It may attain the size of the index finger or even
that of the thumb. "When laid open longitudinally, it at once assumes a
rolled form in the reverse direction.
Ulceration and Perforation of Appendix. — Many cases of ulcer present
no symptoms. In typhoid fever and phthisis eleven instances have come
under my observation in which there were no clinical indications of the
lesion. The dangerous ulcers follow the irritation of the faecal concretions
or foreign bodies. It may result also from obliteration of the caecal end
and distention of the lumen with fluid. The perforation may have the
following direct effects : {a) The appendix may hang free in the peritoneal
cavity, adhesions not having formed, when the perforation at once excites
a diffuse and violent suppurative peritonitis.
{h) More commonly, in fact, almost as a rule, the ulcerated appendix
becomes adherent and a localized peritonitis results. Perforation then
occurs, with the formiition of a circumscribed intraperitoneal abscess
408 DISEASES OF THE DIGESTIVE SYSTEM.
cavity, wliich may be small and which varies in situation with the appen-
dix. Perhaps the most common situation is on the psoas muscle, in the
neighborhood of the terminal portion of the ileum. In cases of this sort I
have most frequently found the small localized abscess just at the angle
between the ileum and the caecum. It may, however, be within the pelvis
or close to the sacrum. Adhesive peritonitis, perforation, and the forma-
tion of a localized abscess may go on without the production of serious
symptoms, and the condition may be found when death has resulted from
accident or some intercurrent affection. In some cases a large circum-
scribed faecal abscess forms in the iliac region and points midway between
the navel and the anterior superior spine of the ilium.
Unfortunately, in many cases the localized abscess cavity excites the
most intense peritonitis. Often without actual rupture diffuse suppura-
tive disease occurs. In many instances the first indication of serious
trouble is the acute, agonizing pain which follows the diffusion of this
localized peritoneal process. The contents of the limited abscess may not
be more than a few cubic centimetres, are usually darkish gray in color,
and excessively offensive.
(6') When the appendix passes behind the caecum and colon and is not
within the peritonaeum, perforation at once produces a retroperitoneal
abscess, which may terminate in many different ways ; thus the pus may
pass beneath the iliacus fascia and appear at Poupart's ligament, in which
situation external perforation may occur and recovery take place. The
pus may be chiefly in the retroperitoneal tissue in the flank, forming
a large perinephritic abscess. In a case under the care of Gardner, of
Montreal, an enormous abscess cavity developed in this situation, which
contained air, pushed up the diaphragm nearly to the second rib, and pro-
duced the symptoms of pneumothorax. Perforation of the pleura may
occur in these cases, forming a faecal pleural fistula. The pus may extend
along the psoas muscle and may perforate the hip joint, or pass to the
neighborhood of the rectum, or produce multiple abscesses of the scrotum,
or, passing through the obturator foramen, form a large gluteal abscess.
Perforation into the bladder may occur, but is not nearly so common as per-
foration into the bowel. In both instances recovery may follow, though
there is greater danger in perforation into the latter. The appendix has
been discharged per anum.
The remote effects of perforative appendicitis are interesting. Iliemor-
rhage may occur. In one of my cases the appendix w^as adherent to the
promontory of the sacrum, and the abscess cavity had perforated in two
places into the ileum. Death resulted from profuse haemorrhage. Cases
are on record in which the internal iliac artery or the deep circumflex iliac
artery has been opened. Suppurative pylephlebitis may result from in-
flammation of the mesenteric veins near the perforated appendix. Two
instances of it have come under my notice ; in one there was a small local-
ized abscess which had resulted from the perforation of a typhoid ulcer
APPENDICITIS. 409
of the appendix. In tlie otlier case, wliich I saw with IMatchell, of Toron-
to, the symptoms were those of septicaemia and suppuration of the liver.
The abscess of the appendix was small and had not produced symptoms.
In the healing of extensive inflammation about the margin of the pelvis
the iliac veins may be greatly compressed, and one of my patients had
for months oedema of the right leg, which is still enlarged.
Symptoms. — As already mentioned, a simple catarrhal appendicitis
may lead to a fatal result, and, on the other hand, perforation and abscess
formation may take place without exciting serious symptoms. No classi-
fication into light, medium, and severe forms can be made, as the most
severe of all features of the disease — general peritonitis — may be the very
first indication of the existence of any trouble.
Catarrhal injlamination may induce the most characteristic features
of appendix disease. The facts on which this statement is made are con-
clusive. A man aged twenty-eight was admitted to the Johns Hopkins
Hospital with pains in the abdomen, localized in the right iliac fossa,
which in July became severe enough to confine him to bed for several
weeks. In August the attack returned with severity. Xo tumor was to
be felt externally, but on rectal examination a firm, rounded body could
be felt high up on the right margin of the pelvis. Laparotomy was per-
formed and the appendix found in the true pelvis, slightly adherent, very
much thickened, but without perforation or ulceration. Bridge reports
an instance in which a woman aged twenty-eight had an attack of severe
abdominal pain, vomiting, constipation, but no tumor. The temperature
rose as high as 101°, the thighs were flexed, and there was pain on exten-
sion of the psoas. Temporary improvement followed and then a recur-
rence, accompanied wdth rise of temperature and return of the pain.
Laparotomy was performed and a thickened, dense appendix found,
which contained three small enteroliths. In both these instances per-
sistent, severe symptoms were caused by what must be termed a chronic
inflammation of the appendix, without ulceration and without perfora-
tion. Both cases recovered. A similar instance has occurred at the
Pennsylvania Hospital, under the care of Thomas G. Morton. A suppu-
rative peritonitis may also occur without perforation or ulceration. In a
case reported by Fitz there had been previous attacks, from which recov-
ery by resolution had taken place ; then an abscess at the brim of the pelvis
was opened and drained. After recovery again a recurrence occurred, and
finally the appendix was removed and found to be thickened, but neither
ulcerated nor perforated, and only adherent in a limited extent to the
omentum.
In 2^erf or at ive appendicitis there may be initial symptoms, such as
nausea, constipation, sometimes diarrhoea, and a sense of uneasiness and
distress in the right iliac fossa. These may possibly be associated with the
localized peritonitis. A sudden violent pain in the abdomen, most com-
monly in the right iliac fossa, is the " most constant, first decided symp-
27
410 DISEASES OF THE DIGESTIVE SYSTEM.
torn of perforating inflammation of the appendix," and occurred in eighty-
four per cent of the cases analyzed by Fitz. It is usually limited to the
fossa, but sometimes extends toward the navel or to the perinaeum, testicle,
or thigh. Fever, furred tongue, and vomiting may precede or accompany
this pain. An initial chill is rare. The temperature ranges from 101° to
103°; sometimes it is higher; the pulse is increased in frequency. The
patient in walking bends over, favors the right side, and has difficulty in
standing straight. When in bed the patient usually lies with the right
leg drawn up and complains of pain on extension. Micturition may be
frequent or there may be retention of urine. Diarrhoea seems to be more
frequent in children than in adults.
Physical Signs. — Tympanites may be early and interfere considerably
with the examination. On the other hand, the abdomen may be flat, hard,
and board-like even with diffuse peritonitis. In a great majority of the
cases there is tenderness in the right iliac fossa and over the region of the
appendix. McBurney has called attention to the value of a special local-
ized point of tenderness on deep pressure situated from one and a half to
two inches from the anterior superior spine of the ileum on a line drawn
between this point and the navel. When firm, continuous pressure is
made with one finger at this point the pain may be of the most exquisite
character. Circumscribed swelling may be present, but it is inconstant
and is not found in more than one half the cases. It is usually in the
fossa below a line passing from the anterior superior spine to the navel
and two or three finger-breadths above Poupart's ligament. In many in-
stances it is a diffuse thickening and induration ; in others a well-defined
tumor mass can be detected. If there is much tension of the abdominal
muscles and pain, it is best to make a thorough examination under ether.
In the cases in which the abscess is large, fluctuation may be felt above
Poupart's ligament or in the flank, and in some instances crepitation.
Dulness is not present unless the exudation is abundant and superficial.
Usually the small localized tumors are entirely masked by the distended
intestines. A rectal examination should be made in every instance. When
the appendix is above the brim of the pelvis it cannot be reached, but
when, as so often happens, it curls over into the pelvis, it or the thick-
ened indurated area about it may be felt. After all, the great danger is
not so much in the limited peritonitis which results from the perforation,
as in the extension of it to the general peritonjBum. In Fitz's analysis,
the second, third, and fourth days included the largest number of cases of
beginning peritonitis. General abdominal pain, tympanites and an aggra-
vation of the general symptoms indicate the onset of this serious compli-
cation.
Diagnosis. — Appendicitis is by far the most common inflammatory
condition producing symptoms, not only in the caecal region but in the
abdomen, generally in persons under thirty. Laparotomy has taught us
that, almost without exception, sudden pain in the right iliac fossa with
APPENDICITIS. 411
fever, localized tenderness with or without tumor, means appendix disease.
Almost the only other local condition to be differentiated is stercoral
caecitis, which is characterized by less severe pain, slighter fever, and the
presence of an elongated doughy mass in the lumbar region ; it must be
remembered that in many of these cases the appendix is probably affected.
Perinephritic and pericaecal abscess from perforation of ulcer, either
simple or cancerous, and circumscribed peritonitis in this region from
other causes can rarely be differentiated until an exploratory incision is
made.
Catarrhal and perforative appendicitis cannot always be differenti-
ated, as the cases which I have quoted show that in intensity of pain,
severity of symptoms, and even in the production of peritonitis, the two
may be identical.
Briefly stated, localized pain in the right iliac fossa with or without
induration or tumor, the existence of McBurney's tender point, fever,
furred tongue, vomiting, constipation or diarrhoea, indicate appendicitis.
The occurrence of general peritonitis is suggested by increase and diffusion
of the abdominal pain, tympanites (as a rule), marked aggravation of the
constitutional symptoms, particularly elevation of fever and increased ra-
pidity of the pulse. Alonzo Clark's sign, obliteration of hepatic dulness,
is rarely present, as the peritonaeum in these cases does not often contain
gas.
The hypodermic needle should never be used unless there is marked
tumor with dulness on percussion in the caecal region.
Intussusception and internal strangulation may present very similar
symptoms, and if the patient is only seen at the latter stages, when there
is diffuse peritonitis and great tympany, the features may be almost iden-
tical. Faecal vomiting, which is common in obstruction, is never seen in
appendicitis, and in children the marked tenesmus and bloody stools are
important signs of intussusception. It is not often difficult when the cases
are seen early and when the history is clear, but mistakes have been made
by surgeons of the first rank.
In women, disease of the tubes and pelvic peritonitis from any cause
may simulate appendicitis; but the history and the local examination,
under ether, should in most cases enable the practitioner to discriminate
between these conditions. In neurotic patients the odd and anomalous
symptoms produced by floating kidney may be thought to be due to ap-
pendicitis.
Prognosis. — If we regard every case of inflammation in the caecal
region as appendicitis, a large proportion of the cases recover. The grav-
ity of the disease is difficult to estimate, but it certainly must be ranked as
one of the most serious and fatal of the abdominal affections of young per-
sons. Post-mortem observations show that very many instances get well,
often without treatment. As mentioned, recurrence is common, so much
so that over forty per cent of the cases may be spoken of as recurrent ap-
412 DISEASES OF THE DIGESTIVE SYSTEM.
pendicitis. Sixty-eight jier cent of the fatal cases die during the first
eiglit days. Extension to the general peritonaeum is almost always fatal.
Perforation into the bowel is often followed by recovery. Perforation
externally is still less serious. Nowadays, with the prompt surgical inter-
ference, the prognosis is very much better.
Treatment. — The studies of Pepper, Noyes, With, and Matterstock,
and more particularly the elaborate and thorough study of Fitz, have
directed the attention of physicians to the clinical features of the diseases
in the caecal region, but to the surgeons we owe invaluable lessons relating
to diagnosis and, above all, to treatment.
The suggestion of Willard Parker with reference to early operation has
been carried out and advocated by Sands, Bull, and Weir in New York,
by Morton and Keen in Philadelphia, and by Treves in London.
Treatment of the Attach. — The medical treatment of appendicitis can
be expressed in three words — rest, opium, and enemata. The patient
should be quiet in bed with an ice-bag placed in the right iliac fossa. If
there is much pain, opium should be given either hypodermically or by
the mouth. Medium-sized injections of warm water may be given twice
daily. I would protest most earnestly against the indiscriminate use of
saline purges, which have been advocated under a total misapprehension.
It cannot be too strongly emphasized that, as a rule, the initial condition,
which produces the pain, the fever, and the local signs, is the establishment
after perforation of a localized peritonitis. So long as the abscess cavity
remains limited, resolution is possible. Saline purges mean more or less
disturbance of the local conditions and a definite increase in the risk of
general peritonitis. It is an entirely different matter when this is estab-
ished. Salines in some instances then do good, but in appendicitis, when
the general peritonaeum is involved, the mischief is done, and neither
salines nor laparotomy materially influence the result.
The profession has yet to learn the lesson that perforative appendicitis
is in more than three fourths of all cases a surgical affection, and perhaps
the most important function of the physician, under whose care the disease
always comes at first, is to say whether the case is suitable and when the
operation should be performed.
Operation is indicated : (a) in all cases of acute inflammatory trouble in
the caecal region when, whether tumor is present or not, the general symp-
toms are severe, as shown by tympany, spreading pain, increase in fever,
and increase in the rapidity of the pulse. In so many of the cases no
tumor is to be felt that stress cannot be laid upon its absence.
{h) When a definite tumor is present, associated with attacks such as
have been described, particularly if they have been recurrent. An occa-
sional exception may be made to this rule wlien, even with small tumor,
the symptoms rapidly subside and the patient improves. We are here on
tlie horns of a dilemma. On the one hand, it is in just such cases that
perforation and fatal peritonitis may at any moment occur, and, on the
INTESTINAL OBSTRUCTION. 413
other, the tumor may gradually disappear and the patient may have no
further trouble.
(c) In recurrent appendicitis, when the attacks are of such severity
and freqiiency as seriously to interrupt the patient's occupation. Is the
interim operation advisable or shall the patient be advised to wait until an
attack ? Opinions differ on this point. It is best, I think, to wait. The
operation has risks ; patients have died from the interim laparotomy ; and
there is always a chance that the recovery from an attack may prove per-
manent. Both clinical observation and morbid anatomy show that com-
plete healing is by no means rare. The physician must be guided too by
the character of the surgical techinque at his command, and could hand
over his patient without qualms to a modern operator whose success has
demonstrated the safety of his methods.
IV. INTESTINAL OBSTRUCTION.
Intestinal obstruction may be caused by strangulation, intussusception,
twists and knots, strictures and tumors, and by abnormal contents.
Etiology and Pathology. — (a) Strangulation.— This is the most
frequent cause of acute obstruction, and occurred in thirty-four per cent
of the 295 cases analyzed by Fitz,* and in thirty-five per cent of the 1,134
cases of Leichtenstern.f Of the 101 cases of strangulation in Fitz's table,
which has the special value of having been carefully selected from the
literature since 1880, the following were the causes : Adhesions, 63 ; vitel-
line remains, 21 ; adherent appendix, 6 ; mesenteric and omental slits, 6 ;
peritoneal pouches and openings, 3 ; adherent tube, 1 ; peduncular tu-
mor, 1. The bands and adhesions result, in a majority of cases, from for-
mer peritonitis. A number of instances have been reported following
operations upon the pelvic organs in women. The strangulation may be
recent and due to adhesion of the bowel to the abdominal wound or a
coil may be caught between the pedicle of a tumor and the pelvic wall.
Such cases are only too common. Late occlusion after recovery from the
operation is due to bands and adhesions.
The vitelline remains are represented by Meckel's diverticulum, which
forms a finger-like projection from the ileum, usually within eighteen
inches of the ileo-caecal valve. It is a remnant of the omphalo-mesenteric
duct, through which, in the early embryo, the intestine communicated
with the yolk-sac. The end, though commonly free, may be attached to
the abdominal wall near the navel, or to the mesentery, and a ring is thus
formed through which the gut may pass.
Seventy per cent of the cases of obstruction from strangulation occur
* Transactions of the Congress of American Physicians and Surgeons, vol. 1, 1889,
The percentages of his tables arc used throughout this section,
f Von Ziemssen's Encyclopa;dia of Practical Medicine.
414 DISEASES OF THE DIGESTIVE SYSTEM.
in males ; forty per cent of all the cases occur between the ages of fifteen
and thirty years. In ninety per cent of the cases of obstruction from
these causes the site of the trouble is in the small bowel ; the position
of the strangulated portion was in the right iliac fossa in sixty-seven
per cent of the cases, and in the lower abdomen in eighty-three per
cent.
(h) Intussusception. — In this condition one portion of the intestine
slips into an adjacent portion, forming an invagination or intussusception.
The two portions make a cylindrical tumor, which varies in length from a
half-inch to a foot or more. The condition is always a descending intus-
susception, and as the jorocess proceeds, the middle and inner layers in-
crease at the expense of the outer layer. An intussusception consists of
three layers of bowel : the outermost, known as the intassuscipiens, or re-
ceiving layer ; a middle or returning layer ; and the innermost or entering
layer. The student can obtain a clear idea of the arrangement by making
the end of a glove-finger pass into the lower portion. The actual condi-
tion can be very clearly studied in the post-mortem invaginations which
are so common in the small bowel of children. In the statistics of Fitz,
93 of 295 cases of acute intestinal obstruction were due to this cause. Of
these, 52 were in males and 27 in females. The cases are most common in
early life, thirty-four per cent under one year and fifty-six per cent under
the tenth year. No definite causes could be assigned in 42 of the cases ;
in the others diarrhcBa or habitual constipation had existed.
The site of the invagination varies. We may recognize (1) an ileo-ccBcal,
when the ileo-caecal valve descends into the colon. There are cases in
which this is so extensive that the valve has been felt per rectum. This
form occurred in seventy-five per cent of the cases. In the ileo-colic the
lower part of the ileum passes through the ileo-caecal valve. (2) The ileal.,
in which the ileum is alone involved. (3) The colic^ in which it is con-
fined to the large intestine. And (4) colico-rectal., in which the colon and
rectum are involved.
Irregular peristalsis is the essential cause of intussusception. Noth-
nagel found in the localized peristalsis caused by the faradic current that
it was not the descent of one portion into the other, but the drawing up
of the receiving layer by contraction of the longitudinal coat. Invagina-
tion may follow any limited, sudden, and severe peristalsis.
In the post-mortem examination, in a case of death from intussuscep-
tion, the condition is very characteristic. Peritonitis may be present or
an acute injection of the serous membrane. Wlien death occurs early, as
it may do from shock, there is little to be seen. The portion of bowel
affected is large and thick, and forms an elongated tumor with a curved
outline. The parts are swollen and congested, owing to the constriction
of the mesentery between the layers. The entire mass may be of a deep
livid-red color. If very recent there is only congestion, and perhaps a
slight layer of lymph, and the intussusception can be reduced, but when it
INTESTINAL OBSTRUCTION. 415
has lasted for a few days, lymj)li is thrown out, the layers are glued to-
gether, and the entering portion of the gut cannot be withdrawn.
The anatomical condition accounts for tlie presence of the tumor, which
exists in two thirds of all cases ; and the engorgement, whicli results from
the compression of the mesenteric vessels, explains the frequent occurrence
of blood in the discharges, which has so important a diagnostic value. If
the patient survives, necrosis and sloughing of the invaginated portion
may occur, and if union has taken place between the middle and outer
layer, the calibre of the gut may be restored and a cure in this way ef-
fected. Many cases of the kind are on record. In the Museum of the
Medical Faculty of McGill University are 17 inches of small intestine,
which were passed by a lad who had had symptoms of internal strangula-
tion, and who made a complete recovery.
(c) Twists and Knots. — Volvulus or twist occurred in 42 of the 295
cases. Sixty-eight per cent were in males. It is most frequent between
the ages of thirty and forty. In the great majority of all cases the twist
is axial and associated with an unusually long mesentery. In fifty per
cent of the cases it was in the sigmoid flexure. The next most common
situation is about the caecum, which may be twisted upon its axis or bent
upon itself. As a rule, in volvulus the loop of bowel is simply twisted
upon its long axis, and the portions at the end of the loop cross each other
and so cause the strangulation. It occasionally happens that one portion
of the bowel is twisted about another.
(d) Strictures and Tumors. — These are very much less important
causes of acute obstruction, as may be judged by the fact that there are
only 15 instances out of the 295 cases, in 14 of which the obstruction oc-
curred in the large intestine. On the other hand, they are common causes
of chronic obstruction.
The obstruction may result from : (1) Congenital stricture. These
are exceedingly rare. Much more commonly the condition is that of com-
plete occlusion, either forming the imperforate anus or the congenital
defect by which the duodenum is not united to the pylorus. (2) Simple
cicatricial stenosis^ which results from ulceration, tuberculous or syphi-
litic, more rarely from dysentery, and most rarely of all from typhoid
ulceration. (3) Neiu groioths. The malignant strictures are due chiefly
to cylindrical epithelioma, which forms an annular tumor, most com-
monly met with in the large bowel, about the sigmoid flexure, or the
descending colon. Of benign growths, papillomata, adenomata, lipomata,
and fibromata occasionally induce obstruction. (4) Compression and trac-
tion. Tumors of neighboring organs, particularly of the pelvic viscera,
may cause obstruction by adhesion and traction ; more rarely, a coil, such
as the sigmoid flexure, filled with faeces, compresses and obstructs a
neighboring coil. In the healing of tuberculous peritonitis the contrac-
tion of the thick exudate may cause compression and narrowing of the
coils.
416 DISEASES OF THE DIGESTIVE SYSTEM.
(e) Abnormal Contents. — Foreign bodies, such as fruit stones, coins,
pins, needles, or fiilse teeth, are occasionally swallowed accidentally, or by
lunatics on purpose. Round worms may become rolled into a tangled
mass and cause obstruction. In reality, however, the majority of foreign
bodies, such as coins, buttons, and pins, swallowed by children, cause no
inconvenience whatever, but in a day or two are found in the stools. Occa-
sionally such a foreign body as a pin will pass through the oesophagus and
will be found lodged in some adjacent organ, as in the heart (Peabody),
or a barley ear may reach the liver (Dock).
Medicines, such as magnesia or bismuth, have been known to accumu-
late in the bowels and produce obstruction, but in the great majority of
the cases the condition is caused by faeces, gall-stones, or enteroliths. Of
44 cases, in 23 the obstruction was by gall-stones^ in 19 by fseces, and in 2
by enteroliths. Obstruction by faeces may happen at any period of life.
As mentioned when speaking of dilatation of the colon, it may occur in
young children and joersist for weeks. In faecal accumulation the large
bowel may reach an enormous size and the contents become very hard.
The retained masses may be channeled, and small quantities of f^cal mat-
ter are passed until a mass too large enters the lumen and causes obstruc-
tion. There may be very few symptoms, as the condition may be borno
for weeks or even for months.
Obstruction by gall-stones is not very infrequent, as may be gathered
from the fact that twenty-three cases were reported in the literature in
eight years. Eighteen of these were in women and five in men. In six
sevenths of the cases it occurred after the fiftieth year. The obstruction
is usually in the ileo-caecal region, but it may be in the duodenum. These
large solitary gall-stones ulcerate through the gall-bladder, usually into
the small intestine, occasionally into the colon. In the latter case they
rarely cause obstruction. Courvoisier has collected one hundred and thirty-
one cases in the literature.
Enteroliths may be formed of masses of hair, more commonly of the
phosphates of lime and magnesia, with a nucleus formed of a foreign body
or of hardened faeces. Nearly every museum possesses specimens of this
kind. They are not so common in men as in ruminants, and, as indicated
in Fitz's statistics, are very rare causes of obstruction.
Symptoms. — (a) Acute Obstruction. — Constipation, pain in the abdo-
men, and vomiting are the three important symptoms. Pain sets in early
and may come on abruptly while the patient is w^alking or, more com-
monly, during the performance of some action. It is at first colicky in
character, but subsequently it becomes continuous and very intense. Vom-
iting follows quickly and is a constant and most distressing symptom. At
first the contents of the stomach are voided, and then greenish, bile-
stained material, and soon, in cases of acute and permanent obstruction,
the material vomited is a brownish -black liquid, with a distinctly faecal
odor. Tliis sequence of gastric, bilious, and, finally, stercoraceous vomit-
INTESTINAL OBSTRUCTION. 417
ing is perhaps the most important diagnostic feature of acute obstruction.
The constipation may be absolute, without the discharge of either faeces
or gas. Very often the contents of the bowel below the stricture are dis-
charged. Distention of the abdomen usually occurs, and when the large
bowel is involved it is extreme. On the other hand, if the obstruction is
high up in the small intestine, there may be very slight tympany. At
first the abdomen is not painful, but subsequently it may become acutely
tender.
The constitutional symptoms from the outset are severe. The face is
pallid and anxious, and finally collapse symptoms supervene. The eyes
become cunken, the features pinched, and the skin is covered with a cold,
clammy sweat. The pulse becomes rapid and feeble. There may be no
fever; the axillary temperature is often subnormal. The tongue is dry
and parched and the thirst is incessant. The urine is high-colored, scanty,
and there may be suppression, particularly when the obstruction is high
up in the bowel. This is probably due to the constant vomiting and the
small amount of liquid which is absorbed. The cas3 terminates as a rule
in from three to six days. In some instances the patient dies from shock
or sinks into coma.
(b) Symptoms of Chronic Obstruction. — When due to faecal impaction,
there is a history of long-standing constipation. There may have been
discharge of mucus, or in some instances the faecal masses have been chan-
neled, and so have allowed the contents of the upper portion of the
bowel to pass through. In elderly persons this is not infrequent; but
examination, either per rectum or externally, in the course of the colon,
will reveal the presence of hard scybalous masses. There may be retention
of faeces for weeks without exciting serious symptoms. In other instances
there are vomiting, pain in the abdomen, gradual distention, and finally
the ejecta become faecal. The hardened masses may excite an intense
colitis or even peritonitis.
In stricture, whether cicatricial or cancerous, the symptoms of obstruc-
tion are very diverse. Constipation gradually comes on, is extremely varia-
ble, and it may be months or even years before there is complete obstruc-
tion. There are transient attacks, in which from some cause the fasces
accumulate above the stricture, the intestine becomes greatly distended,
and in the swollen abdomen the coils can be seen in active peristalsis. In
such attacks there may be vomiting, but it is very rarely of a faecal char-
acter. In the majority of these cases the general health is seriously im-
paired ; the patient gradually becomes anaemic and emaciated, and finally,
in an attack in which the obstruction is complete, death occurs with all
the features of acute occlusion or the case may be prolonged for ten or
twelve days.
Diagnosis. — (a) The Situation of the Obstruction. — Hernia must
be excluded, which is by no means always easy, as fatal obstructi-on may
occur from the involvement of a very limited portion of the gut in the
418 DISEASES OP THE DIGESTIVE SYSTEM.
external ring or in the obturator foramen. Mistakes from both of these
causes have come under my observation ; they were cases in which it was
im2)ossible to make a diagnosis other than acute obstruction. Timely
operation would have saved both lives. A thorough rectal and vaginal
examination should be made, which will give important information as to
the condition of the pelvic and rectal contents, particularly in cases of
intussusception, in which the descending bowel can sometimes be felt. In
cases of obstruction high up the empty coils sink into the pelvis and can
there be detected. Kectal exploration with the entire hand is of doubtful
value. In the inspection of the abdomen there are important indications,
as the special prominence in certain regions, the occurrence of definite,
well-defined masses, and the presence of hypertrophied coils in active
peristalsis. In obstruction in the duodenum or jejunum there may only
be slight distention in the upper part of the abdomen, associated usually
with rapid collapse and anuria.
In the ileum and caecum the distention is more in the central portion
of the abdomen ; the vomiting is distinctly faecal and occurs early. In
obstruction of the colon, tympanites is much more extensive and general.
Tenesmus is more common, with the passage of mucus and blood. The
course is not so quick, the collapse does not supervene so rapidly, and the
urinary secretion is not so much reduced.
In obstruction from stricture or tumor the situation can in some cases
be accurately localized, but in others it is very difficult. Digital examina-
tion of the rectum should first be made. The rectal tube may then be
passed, but it is impossible to get beyond the sigmoid flexure. In the use
of the rigid tube there is danger of perforation of the bowel in the neigh-
borhood of a stricture. The quantity of fluid which can be passed into
the large intestine should be estimated. The capacity of the large bowel
is about six quarts. The safe limits of pressure have been determined to
be under ten feet in an infant and twenty feet in an adult. To thorough-
ly irrigate the bowel the patient should be chloroformed and should lie on
the back or on the side ; best on the back with the hips elevated. Treves
suggests that the caecal region should be auscultated during the passage of
the fluid. For diagnostic purposes the rectum may be inflated, either by
the bellows or by the use of bicarbonate of soda and tartaric acid. In cer-
tain cases these measures give important indications as to the situation of
the obstruction in the large bowel.
(h) Nature of the Obstruction. — This is often difficult, not infrequent-
ly impossible, to determine. Strangulation is not common in very early
life. In many instances there have been previous attacks of abdominal
pain, or tlicre are etiological factors which give a clew, such as old peri-
tonitis or operation on tlie pelvic viscera. Neitlier the onset nor the char-
acter of the pain gives us any information. In rare instances nausea and
vomiting may be absent. The vomiting usually becomes faecal from the
third to the fifth day. A tumor is not common in strangulation, and
INTESTINAL OBSTRUCTION. 419
was present in only one fifth of the cases. Fever is not of diagnostic
value.
Intussusception is an affection of childhood, and is of all forms of in-
ternal obstruction the one most readily diagnosed. Tlic presence of tumor,
bloody stools, and tenesmus are the important factors. The tumor is
usually sausage-shaped and felt in the region of the transverse colon. It
existed in QQ of 93 cases. It was present on the first day in more than one
third of the cases, on the second day in more than one fourth, and on the
third day in more than one fifth. Blood in the stools occurs in at least
three fifths of the cases, either spontaneously or following the use of an
enema. The blood may be mixed with mucus. Tenesmus is present in
one third of the cases. Faecal vomiting is not very common and was pres-
ent in only 12 of the 93 instances. Abdominal tympany is a symptom of
slight importance, occurring in only one third of the cases.
Volvulus can rarely be diagnosed. The frequency with which it in-
volves the sigmoid flexure is to be borne in mind. The passage of a flex-
ible tube or injecting fluids might in these cases give valuable indications.
An absolute diagnosis can probably be made only by an abdominal section.
In f cecal ohstruction the condition is usually clear, as the faeces can be
felt per rectum and also in the distended colon. Faecal vomiting, tym-
pany, abdominal pain, nausea, and vomiting are late and are not so con-
stant. In obstruction by gall-stone a few of the cases gave a previous his-
tory of gall-stone colic. Jaundice was present in only two of the twenty-
three cases. Pain and vomiting, as a rule, occur early and are severe, and
faecal vomiting is present in two thirds of the cases. A tumor is rarely
evident.
(c) Diagnosis from other Conditions. — Acute enteritis with great re-
laxation of the intestinal coils, vomiting, and pain may be mistaken for
obstruction. In an autopsy on a case of this kind the small and large
bowels were intensely inflamed, relaxed, sodden, and enormously distended.
The symptoms were those of acute obstruction, but the intestine was free
from duodenum to rectum. Of late years many instances have been re-
ported in which peritonitis following disease of the appendix has been
mistaken for acute obstruction. The intense vomiting, the general tym-
pany and abdominal tenderness, and in some instances the suddenness of
the onset are very deceptive, and in two cases which have come under my
notice the symptoms pointed very strongly to internal strangulation. In
appendix disease the temperature is more frequently elevated, the vomit-
ing is never faecal, and in many cases there is a history of previous attacks
in the caecal region. Acute haemorrhagic pancreatitis may produce symp-
toms which simulate closely intestinal obstruction. A boy was admitted
to the Johns Hopkins Hospital with a history of obstinate vomiting, in-
tense abdominal pain, gradually increasing tympany, and no passage for
several days. His condition seemed serious and he was transferred at once
to the surgical wards. At the operation the coils were found uniformly
420 DISEASES OP THE DIGESTIVE SYSTEM.
distended and covered in places with the thinnest film of lymph. No
obstruction existed, but there was a tumor-like mass surrounding the pan-
creas, firm, hard, and deeply infiltrated with blood. The patient improved
after the operation and recovered completely.
Treatment. — Purgatives should not be given. For the pain h}^)©-
dermics of morphia are indicated. To allay the distressing vomiting, the
stomach should be washed out. Not only is this directly beneficial, but
Kiissmaul claims that the abdominal distention is relieved, the pressure in
the bowel above the seat of obstruction is lessened, and the violent peri-
stalsis is diminished. It may be practised three or four times a day, and
in some instances has proved beneficial ; in others curative. Thorough
irrigation of the large bowel with injections should be practised, the fluid
being allowed to flow in from a siphon syringe, and the amount carefully
estimated. Jonathan Hutchinson recommends that the patient be placed
under an anaesthetic, the abdomen thoroughly kneaded, and a copious
enema given while in the inverted position. Then, with the aid of three
or four strong men, the patient is to be thoroughly shaken, first with the
abdomen held downward, and subsequently in the inverted position.
Inflation may also be tried, by forcing the air into the rectum with the
bellows or with a Davidson's syringe. It is a measure not without risk,
as instances of rupture of the bowel have been reported. Fitz's figures
show that in the first eight years of the last decade there were thirty-three
cases of recovery after injection or inflation in cases of certain or probable
intussusception, and eleven deaths. In cases of acute obstruction, if these
means do not prove successful by the third day, surgical measures should
be resorted to, and when the obstruction seems persistent and the condi-
tion serious, laparotomy should be performed at once.
For the tympanites turpentine stupes and hot applications may be
applied ; if extreme, the bowel may be punctured with a small aspirator
needle. In cases of chronic obstruction the diet must be carefully regu-
lated, and opium and belladonna are useful for the paroxysmal pains.
Enemata should be employed, and if the obstruction becomes complete,
resort must be had to surgical measures.
V. CONSTIPATION (Costiveness).
Definition. — detention of faeces from any cause.
Constipation in Adults. — The causes are varied and may be classed as
general and local.
General Causes.— {a) Constitutional peculiarities: Torpidity of the
bowels is often a family comj)laint and is found more often in dark than
in fair persons, (h) Sedentary habits, particularly in persons who eat too
much and neglect tlie calls of nature, (c) Certain diseases, such as anae-
mia, neurasthenia and hysteria, chronic affections of the liver, stomach,
CONSTIPATION. 421
and intestines, and the acute fevers. Under tliis heading may appropri-
ately be placed that most injurious of all habits, drug -talcing, (d) Either
a coarse diet, which leaves too much residue, or a diet which leaves too
little may be a cause of costiveness.
Local Causes. — Weakness of the abdominal muscles in obesity or from
overdistention in repeated pregnancies. Atony of the large bowel from
chronic disease of the mucosa ; the presence of tumors, physiological or
pathological, pressing upon the bowel ; enteritis ; foreign bodies, large
masses of scybala, and strictures of all kinds. By far the most important
local cause is atony of the colon, particularly of the muscles of the sig-
moid flexure by which the faeces are propelled into the rectum.
Symptoms. — The most persistent constipation for weeks or even
months may exist with fair health. All kinds of evils have been attrib-
uted to poisoning by the resorption of noxious matters from the retained
faeces — copraemia — but it is not likely that this takes place to any extent.
Chlorosis, which Sir Andrew Clark attributes to fa3cal poisoning, is not
always associated with constipation, and if due to this cause should be in
men, women, and children the most common of all disorders. Debility,
lassitude, and mental depression are frequent symptoms in constipation,
particularly in persons of a nervous temperament. Headache, loss of ap-
petite, and a furred tongue may also occur. Individuals differ extraor-
dinarily in this matter ; one feels wretched all day without the accustomed
evacuation ; another is comfortable all the week except on the day on
which by purge or enema the bowels are relieved.
When persistent, the accumulation of f^ces leads to unpleasant, some-
times serious symptoms, such as piles, ulceration of the colon, distention
of the sacculi, perforation, enteritis, and occlusion. In women pressure
may cause pain at the time of menstruation and a sensation of fulness
and distention in the pelvic organs. Neuralgia of the sacral nerves may
be caused by an overloaded sigmoid flexure. The faeces collect chiefly in
the colon. Even in extreme grades of constipation it is rare to find dry
faeces in the caecum. The faeces may form large tumors at the hepatic or
splenic flexures, or a sausage-like, doughy mass above the navel, or an
irregular lumpy tumor in the left inguinal region. In old persons the
sacculi of the colon become distended and the scybala may remain in
them and undergo calcification, forming enteroliths.
In cases with prolonged retention the fa3cal masses become channelled
and diarrhoia may occur for days before the true condition is discovered
by rectal or external examination. In women who have been habitually
constipated, attacks of diarrhoea with nausea and vomiting should excite
suspicion and lead to a thorough examination of the large bowel. Fever
may occur in these cases, and Meigs has reported an instance in which
the condition simulated typhoid fever.
Constipation in infants is a common and troublesome disorder. The
causes are congenital, dietetic, and local. There are instances in which
422 DISEASES OF THE DIGESTIVE SYSTEM.
the child is constipated from birth and may not have a natural movement
for years and yet thrive and develop. An instance of the kind was in my
ward recently in which a baby of seven months had never had a movement
without preliminary injections. The abdomen became swollen every day,
but subsided after an injection and the passage of a long catheter. No
stricture could be felt. I have already referred to a case of W. E. Hughes's,
in which there was enormous dilatation of the large bowel with persistent
constipation. In some of these patients there may be constricting bands,
or, as in a case of Cheever's, a congenital stricture.
Dietetic causes are more common. In sucklings it often arises from
an unnatural drjmess of the small residue which passes into the colon, and
it may be very difficult to decide whether the fault is in the mother's milk
or in the digestion of the child. Most probably it is the latter, as some
babies may be persistently costive on natural or artificial foods. Too
much casein in the milk is believed by some Avriters to be the cause. In
older children it is of the greatest importance that regular habits should
be enjoined. Carelessness on the part of the mother in this matter often
lays the foundation of troublesome constipation in after life. Impairment
of the contractibility of the intestinal wall in consequence of inflamma-
tion, disturbance in the normal intestinal secretions, and mechanical
obstruction by tumors, twists, and intussusception are the chief local
causes.
Treatment. — Much may be done by systematic habits, particularly
in the young. The desire to go to stool should always be granted. Exer-
cise in moderation is helpful. In stout persons and in women with pend-
ulous abdomens the muscles should have the support of a bandage.
Friction or regularly applied massage is invaluable in the more chronic
cases. A good substitute is a metal ball weighing from four to six pounds,
which may be rolled over the abdomen every morning for five or ten min-
utes. The diet should be light, with plenty of fruit and vegetables, par-
ticularly salads and tomatoes. Oatmeal is usually laxative, though not to
all ; brown bread is better than that made from fine white flour. Of
liquids, water and the aerated mineral waters may be taken freely. A
tumblerful of cold water on rising, taken slowly, is efficacious in many
cases. A glass of hot water at night may also be tried alone. A pipe or
a cigar after breakfast is with many men an infallible remedy.
AVhen the condition is not very obstinate it is well to try to relieve
it by hygienic and dietetic measures. If drugs must be used they should
be the milder saline laxatives or the compound liquorice powder. Enemata
are often necessary, and it is much preferable to employ them early than
to constantly use purgative pills. Glycerine either in the form of sup-
pository or as a small injection is very valuable. Half a drachm of boric
acid placed within the rectum is sometimes efficacious. The injections of
tepid water, with or without soap, may be used for a prolonged period
with good effect and without damage. The patient should be in the
JAUNDICE. 423
dorsal position with the hips elevated, and it is best to let the fluid flow in
slowly from a fountain syringe.
There are various drugs which are of special service, particularly the
combination of ipecacuanha, nux vomica, or belladonna, with aloes, rhu-
barb, colocynth, or podophyllin. Meigs recommends particularly the
combination of extract of belladonna (gr. -j^), extract of nux vomica (gr.
i), and extract of colocynth (gr. ij), one pill to be taken three times a
day. In anaemia and chlorosis a sulphur confection taken in the morn-
ing, and a pill of iron, rhubarb, and aloes throughout the day are very
serviceable.
In children the indications should be met, as far as possible, by hygienic
and dietetic measures. In the constipation of sucklings a change in the
diet of the mother may be tried. Drinking of water, barley water, or oat-
meal water will sometimes obviate the difficulty. If laxatives are required
simple syrup, manna, or olive oil may be sufficient. The conical piece of
soap, so often seen in nurseries, is sometimes efficacious. Small injections
of cold water may be used. Large injections should be avoided if possi-
ble. If it is necessary to give a laxative by the mouth the castor oil or
fluid magnesia is the best. If there are signs of gastro-intestinal irritation
rhubarb and soda or gray powder may be given. In older children the
diet should be carefully regulated.
YIII. DISEASES OF THE LIYER.
I. JAUNDICE {Icterus),
1. Jaundice as a Symptom. — Cases with icterus may be divided into
two grert groups : Those in which there is obstruction, either in the small-
er or in the larger ducts — the hepatogenous form ; cases in which the jaun-
dice is due to suppression of the function of the liver-cells, as in the wide-
spread necrosis of acute yellow atrophy, or to an excess of the chroma-
togenous material, as in malaria, pernicious anaemia, and certain fevers, in
which the liver function cannot keep pace with the blood destruction
(haemolysis) — iKsmatogenous or non-obstructive jaundice.
The following classification of the causes of hepatogenous jaundice is
arranged by Murchison, to whose writings on the liver we owe so much :
Obstruction (1) by foreign bodies within the ducts, as gall-stones and
parasites ; (2) by inflammatory tumefaction of the duodenum or of the
lining membrane of the duct ; (3) by stricture or obliteration of the duct ;
(4) by tumors closing the orifice of the duct or growing in its interior ;
(5) by pressure on the duct from without, as by tumors of the liver itself,
of the stomach, pancreas, kidney, or omentum ; by pressure of enlarged
glands in the fissure of the liver, and, more rarely, of abdominal aneurism,
424 DISEASES OF THE DIGESTIVE SYSTEM.
fjecal accnmulation, or the pregnant uterus ; (G) to these may be added
lowering of tlie blood pressure in the liver, so that the tension in the
smaller bile-ducts is greater than in the blood-vessels. In this class very
probably may be placed the cases resulting from mental shock or depress-
ing emotions.
General Symptoms of Obstructive Jaundice. — (1) Icterus, or tinting
of the skin and conjunctivae. The color ranges from a lemon-yellow in
catarrhal jaundice to a deep olive-green or bronzed hue in permanent
obstruction. In some instances the color of the skin is greenish black,
the so-called " black jaundice."
(2) Of other cutaneous symptoms, pruritus in the more chronic forms
may be intense and cause the greatest distress. It may precede the onset
of the jaundice, but as a rule it is not very marked except in cases of pro-
longed obstruction. Sweating is common, and may be curiously localized
to the abdomen or to the palms of the hands. Lichen, urticaria, and
boils may develop, and the skin disease known as xanthelasma or vitili-
goidea.
(3) The secretions are colored with bile-pigment. The sweat tinges
the linen ; the tears and saliva and milk are rarely stained. The expecto-
ration is not often tinted unless there is inflammation, as when pneumonia
coexists with jaundice. The urine may contain the pigment before it is
apparent in the skin or conjunctiva. The color varies from light greenish
yellow to a deep black-green. Gmelin's test is made by allowing five or
six drops of urine and a similar amount of common nitric acid to flow
together slowly on the flat surface of a white plate. A play of colors is
produced — various shades of green, yellow, violet, and red. In cases of
jaundice of long standing or great intensity the urine usually contains
albumen and always bile-stained tube-casts.
(4) No bile passes into the intestine. The stools therefore are of a
pale drab or slate-gray color, and usually very fetid and pasty. There
may be constipation ; in many instances, owing to decomposition, there is
diarrhoea.
(5) Slow pulse. The heart's action may fall to 40, 30, or even to 20
per minute. It is particularly noticeable in the cases of catarrlial jaun-
dice, and is not as a rule an unfavorable symptom.
(G) Haemorrhage. Ecchymoses are not uncommon in severe jaundice,
particularly in the more malignant forms.
(7) Cerebral symptoms. Irritability, great depression of spirits, or
even melancholia may be present. In any case of persistent jaundice
special nervous phenomena may develop and rapidly prove fatal — such as
sudden coma, acute delirium, or convulsions. Usually the patient has a
rapid pulse, slight fever, and a dry tongue, and lie passes into the so-called
" t}7ilioid state." These features are not nearly so common in obstructive
as in febrile jaundice, but tliey not infrequently terminate a chronic icterus
in whatever way produced. The group of symptoms has been termed
JAUNDICE. 425
cJwIcemia or, on the supposition that cliolesterin is the poison, cJiolesier-
(Binia ; but the true nature of the poison lias not yet been determined. In
some of the cases the symptoms may be due to uraemia.
Non-obstrmctive jaundice may be thus classified :
(1) The form in which there is wide-spread necrosis of the liver-cells
and direct interference with their bile-forming function, as in acute yellow
atrophy, and possibly in certain cases of hypertrophic cirrhosis. Strictly
speaking, this is a hepatogenous jaundice.
(2) The toxic form. The poisons of yellow fever, malaria, typhoid,
epidemic jaundice, and pyaemia ; snake virus, as well as chloroform, ether,
phosphorus, and mercury, act by causing increased destruction of the red
blood-corpuscles. More blood-pigment is set free than can be disposed of
by liver, spleen, or kidneys, and the bilirubin (transformed hagmoglobin)
is deposited in the tissues. The symptoms of hsematogenous jaundice are
not nearly so striking as in the obstructive variety. The skin has in many
cases only a light lemon tint. In the severer forms, as in acute yellow
atrophy, the color may be more intense, but in malaria, and pernicious
anaemia the tint is usually light. In these mild cases the urine may con-
tain little or no bile-pigment, but the urinary pigments are considerably
increased. The stools are not clay-colored and may in some instances be
very dark. In the toxic forms of this variety the cerebral symptoms are
marked and there may be active delirium, coma, or convulsions.
2. Icterus Neonatorum. — New-born infants are liable to jaundice, which
in some instances rapidly proves fatal. A mild and a severe form may be
recognized.
The mild icterus of the new-born is a common disease in foundling
hospitals and is not very infrequent in private practice. The discoloration
appears early, usually on the first or second day, and is of moderate inten-
sity. The urine may be bile-stained and the faeces colorless. The nutri-
tion of the child is not seriously disturbed, and in the majority of cases
the jaundice disappears within two weeks. It is supposed that the dimin-
ished pressure in the portal vessels, following the severance of the placental
circulation, allows absorption from the bile capillaries, in which the tension
is greater. Possibly too, as Quincke suggests, the ductus venosus may
remain open, allowing some of the portal blood containing bile to flow
into the systemic circulation. On the other hand, it is held that the jaun-
dice is haematogenous and due to the destruction of large numbers of red
blood-corpuscles during the first few days after birth.
The severe form of icterus in the new-born may depend upon {a) con-
genital absence of the common or hepatic duct, of which there are sev-
eral instances on record ; {h) congenital syphilitic hepatitis ; and {c) sep-
tic poisoning, associated with phlebitis of the umbilical vein. This is a
severe and fatal form, in which also haemorrhage from the cord may
occur.
28
426 DISEASES OF THE DIGESTIVE SYSTEM.
Occasionally jaundice sets in and persists for many weeks, or even
months, without interfering seriously with the nutrition of the child.
3. Acute Yellow Atrophy of the Liver; Malignant Jaundice; Icterus
Gravis.
Definition. — Jaundice associated with marked cerebral symptoms
and characterized anatomically by extensive necrosis of the liver-cells with
reduction in volume of the organ.
Etiology. — This is a rare disease. In a somewhat varied post-mor-
tem and clinical experience no instance has fallen under my observation.
On the other hand, a physician may see several cases within a few years,
or even within a few months, as happened to Riess, who saw five cases
within three months at the Charite, in Berlin. The disease seems to
be rare in this country. No case is reported in the Transactions of the
Pathological Societies of New York (Vols. I to III) or of Philadelphia
(Vols. I to XIII). The disease is more common in women than in men.
Of the 100 cases collected by Legg, 69 were in females ; and of Thierfel-
der's 143 cases, 88 were in women. There is a remarkable association
between the disease and pregnancy, which was present in 25 of the 69
women in Legg's statistics, and in 33 of the 88 women in Thierfelder's
collection. It is most common between the ages of twenty and thirty, but
is occasionally seen in young children. It has followed fright or profound
mental emotion. Though the symptoms produced by phosphorus poison-
ing closely simulate those of acute yellow atrophy, the two conditions are
not identical.
Morbid Anatomy. — The liver is greatly reduced in size, looks thin
and flattened, and sometimes does not reach more than one half or even
one third of its normal weight. It is flabby and the capsule is wrinkled.
On section the color is of a yellowish brown, yellowish red, or mottled,
and the outlines of the lobules are indistinct. The yellow and dark-red
portions represent different stages of the same process — the yellow an ear-
lier, the red a more advanced stage. The organ may cut with considerable
firmness. Microscopically the liver-cells are seen in all stages of necrosis,
and in spots appear to have undergone complete destruction, leaving a
fatty, granular debris with pigment grains and crystals of leucin and tyro-
sin. Tlie interlobular tissue may be normal, but in many cases there is a
marked proliferation of small cells, which was present in 9 of the 12 cases
examined by Riess. Micro-organisms have been noted by several observ-
ers. The bile-ducts and gall-bladder are empty.
The other organs show extensive bile staining, and there are numerous
haemorrhages. The kidneys may show marked granular degeneration of
the epithelium, and usually there is fatty degeneration of the heart. In a
majority of the cases the spleen is enlarged.
Symptoms. — In the initial stage there is a gastro-duodenal catarrh,
and at first the jaundice is thought to be of a simple nature. In some in-
AFFECTIONS OF THE JJLOOD-VESSKLS OF THE LlVEll. 427
stances this lasts only a few days, in others two or three weeks. Then
severe symptoms set in — headache, delirium, trembling of the muscles, and,
in some instances, convulsions. Vomiting is a constant symptom, and
blood may be brought up. Ilaamorrhagcs occur into the skin or from the
mucous surfaces; in pregnant women abortion may occur. With the de-
velopment of the head symptoms the jaundice usually increases. Coma sets
in and gradually deepens until death. The body temperature is variable ;
in a majority of the cases the disease runs an afebrile course, though some-
times just before death there is an elevation. In some instances, however,
there has been marked pyrexia. The pulse is usually rapid, the tongue
coated and dry, and the patient is in a " typhoid state."
The urine is bile-stained and often contains tube-casts. Leucin and
tyrosin are constantly present ; the former as rounded disks, the latter in
needle-shaped crystals, arranged either in bundles or in groups. The
tyrosin may sometimes be seen in the urine sediment, but it is best first to
evaporate a few drops of urine on a cover-glass. In the majority of cases
no bile enters the intestines, and the stools are clay-colored. The dis-
ease is almost invariably fatal. In a few instances recovery has been
noted. I saw in Leube's clinic, at Wurzburg, a case which was convales-
cent.
Diagnosis. — Jaundice with delirium, diminution of the liver volume,
delirium, and the presence of leucin and tyrosin in the urine, form a char-
acteristic and unmistakable group of symptoms.
It is not to be forgotten that any severe jaundice may be associated
with intense cerebral symptoms. The clinical features in certain cases of
h3rpertrophic cirrhosis are almost identical, but the enlargement of the
liver, the more constant occurrence of fever, and the absence of leucin
and tyrosin are distinguishing signs. Phosphorus poisoning may closely
simulate acute yellow atrophy, particularly in the hasmorrhages, jaundice,
and the diminution in the liver volume, but the gastric symptoms are
usually more marked, and leucin and tyrosin are stated not to occur in the
urine.
No known remedies have any influence on the course of the disease.
II. AFFECTIONS OF THE BLOOD-VESSELS OF THE LIVER.
(1) AnSBmia. — On the post-mortem table, when the liver looks anaemic,
as in the fatty or amyloid organ, the blood-vessels, which during life were
probably well filled, can be readily injected. There are no symptoms in-
dicative of this condition.
(2) Hyperaemia. — This occurs in two forms, (a) Active hyperemia.
After each meal the rapid absorption by the portal vessels induces transient
congestion of the organ, which, however, is entirely physiological ; but it
is quite possible that in persons who persistently eat and drink too much
42S DISEASES OF THE DIGESTIVE SYSTEM.
this active hypergemia may lead to functional disturbance or, in the case
of drinking too freely of alcohol, to organic change.
The symjHoms of active hyperaemia are indefinite. Possibly the sense
of distress or fulness in the right hypochondrium, so often mentioned by
dyspeptics and by those who eat and drink freely, may be due to this
cause. There are probably diurnal variations in the volume of the liver.
In cirrhosis with enlargement the rapid reduction in volume after a copi-
ous hsemorrhage indicates the important part which hyperaemia plays even
in organic troubles. It is stated that suppression of the menses or sup-
pression of a haemorrhoidal flow is followed by hyperaemia of the liver.
Andrew H. Smith has described a case of periodical enlargement of the
liver.
(/;) Passive Congestion. — This is much more common and results from
an increase of pressure in the efferent vessels or sub-lobular branches of the
hepatic veins. Every condition leading to venous stasis in the right heart
at once affects these veins.
In chronic valvular disease, in emphysema, cirrhosis of the lung, and
in intrathoracic tumors mechanical congestion occurs and finally leads to
very definite changes. The liver is enlarged, firm, and of a deep-red color ;
the hepatic vessels are greatly engorged, particularly the central vein in
each lobule and its adjacent capillaries. On section the organ presents a
peculiar mottled appearance, owing to the deeply congested hepatic and
the anaemic portal territories ; hence the term nutmeg which has been
given to this condition. Gradually the distention of the central capillaries
reaches such a grade that atrophy of the intervening liver-cells is induced.
Brown pigment is deposited about the centre of the lobules and the con-
nective tissue is greatly increased. In this cyanotic induration or cardiac
liver the organ is large in the early stage, but later it may become con-
tracted. Occasionally in this form the connective tissue is increased about
the lobules as well, byt the process usually extends from the sublobular and
central veins.
The symptoms of this form are not always to be separated from those
of the associated conditions. Gastro-intestinal catarrh is usually present
and haematemesis may occur. The portal obstruction in advanced cases
leads to ascites, which may precede the development of general dropsy.
There is often slight jaundice, the stools may be clay-colored, and the
urine contains bile-pigment.
On examination the organ is found to be increased in size. It may be
a full hand's-breadth below the costal margin and tender on pressure. It
is in this condition particularly that we meet with pulsation of the liver.
We must distinguish the communicated throbbing of the heart, which is
very common, from the heaving, diffuse impulse due to regurgitation into
the hepatic veins, in which, when one hand is upon the ensiform cartilage
and the other upon the right side at the margin of the ribs, the whole
liver can be felt to dilate with each impulse.
AFFECTIONS OF THE BLOOD-VESSELS OF THE LIVER. 429
The indiciitions for treatment in passive liyperaemia are to restore tlio
balance of the circulation and to unload the engorged portal vessels. In
cases of intense hyperajmia eighteen or twenty ounces of blood may be
directly aspirated from tlie liver, as advised by George Ilarley and prac-
tised by many Anglo-Indian physicians. Good results sometimes follow
this hepato-phlebotomy. The prompt relief and marked reduction in the
volume of the organ which follow an attack of haematemesis or bleeding
from piles suggests this practice. Salts administered by Matthew Hay's
method deplete the portal system freely and thoroughly. As a rule, the
treatment must be that of the condition w4th which it is associated.
(3) Diseases of the Portal Vein. — {a) Thrombosis ; Adhesive Pyle-
phlehitis. — Coagulation of blood in the portal vein is rarely seen except in
cirrhosis. Exceptional causes are invasion of the branches by cancer, pro-
liferative peritonitis involving the gastro-hepatic omentum, and perfora-
tion of the vein by gall-stones. In rare instances a complete collateral cir-
culation is established, the thrombus undergoes the usual changes, and
ultimately the vein is represented by a fibrous cord, a condition which has
been called injlephWbitis adhesiva. In a case of this kind which I dissect-
ed the portal vein was represented by a narrow fibrous cord ; the collateral
circulation, which must have been completely established for years, ulti-
mately failed, ascites and haematemesis supervened and rapidly proved
fatal.* The diagnosis of obstruction of the portal vein can rarely be
made. A suggestive symptom, however, is a sudden onset of the most
intense engorgement of the branches of the portal system.
Emboli in the branches of the portal vein do not, as a rule, produce
infarction, for blood reaches the lobular capillary plexus, as shown by
Cohnheim and Litten, through the free anastomosis with the hepatic
artery. In rare instances, however, a condition resembling infarction does
occur, sometimes in small areas, at others in quite extensive territories.
Septic emboli, on the other hand, may induce suppuration.
{h) Suppurative pylephlebitis will be considered in the section on
abscess.
(4) Affections of the hepatic vein are extremely rare. Dilatation
occurs in cases of chronic enlargement of the right heart, from whatever
cause produced. Emboli occasionally pass from the right auricle into the
hepatic veins. A rare and unusual event is stenosis of the orifices of the
hepatic veins, which I met in a case of fibroid obliteration of the inferior
vena cava and was associated with a greatly enlarged and indurated liver, f
(5) Hepatic Artery. — Enlargement of this vessel is seen in cases of
cirrhosis of the liver. It may be the seat of extensive sclerosis. Aneurism
of the hepatic artery is rare, but instances are on record, and will be re-
ferred to in the section on arteries.
* Journal of Anatomy and Physiology, vol. xvii.
f Ibid., vol. xvi.
430 DISEASES OF THE DIGP^STIVE SYSTEM.
III. DISEASES OF THE BILE-PASSAGES.
Catarrhal Jaui^dice.
Definition. — Jaundice due to swelling and obstruction of the terminal
portion of the common duct.
Etiology. — General catarrhal inflammation of the bile-ducts is usu-
ally associated with gall-stones. The catarrhal process now under consid-
eration is probably always an extension of a gastro-duodenal catarrh, and
the process is most intense in the pars ititestinalis of the duct, which
projects into the duodenum. The mucous membrane is swollen, and a
plug of inspissated mucus fills the diverticulum of Vater, and the narrower
portion just at the orifice, completely obstructing the outflow of bile. It
is not known how wide-spread this catarrh is in the bile-passages, and
whether it really passes up the ducts. It would, of course, be possible to
have a catarrh of the finer ducts within the liver, which some French writ-
ers think may initiate the attack, but the evidence of this is not strong,
and it seems more likely that the terminal portion of the duct is always
first involved. In the only instance which I have had an opportunity to
examine post mortem the orifice was plugged with inspissated mucus, the
common and hepatic ducts were slightly distended and contained a bile-
tinged, not a clear, mucus, and there were no observable changes in the
mucosa of the ducts.
This catarrhal or simple jaundice results from the following causes :
(1) Duodenal catarrh, in whatever way produced, most commonly fol-
lowing an attack of indigestion. It is most frequently met with in young
persons, but may occur at any age, and may follow not only errors in diet,
but also cold, exposure, and malaria, as well as the conditions associated
with portal obstruction, chronic heart-disease, and Bright's disease. (2)
Emotional disturbances may be followed by jaundice, which is believed to
be due to catarrhal swelling. Cases of this kind are rare and the anatom-
ical condition is unknown. (3) Simple or catarrhal jaundice may occur
in epidemic form. (4) Catarrhal jaundice is occasionally seen in the in-
fectious fevers, such as pneumonia, and typhoid fever.
Symptoms. — There may be neither pain nor distress, and the
patient's friends may first notice the yellow tint, or the patient himself
may observe it in the looking-glass. In other instances there are dyspep-
tic symptoms and uneasy sensations in the hepatic region or pains in the
back and limbs. In the epidemic form, the onset may be more severe,
with headache, chill, and vomiting. Fever is rarely present, though the
temperature may reach 101°, sometimes 102°. All the signs of obstruct-
ive jaundice already mentioned are present, the stools are clay-colored,
and the urine contains bile-pigment. The jaundice has a bright-yellow
tint; the greenish, bronzed color is never seen in the simple form. The
pulse may be normal, but occasionally it is remarkably slow, and may fall
diseasp:s of the bile-passages. 431
to forty or thirty beats in the minute. The liver may be normal in size,
but is usually slightly enlarged, and the edge can be felt below the costal
margin. Occasionally the enlargement is more marked. The duration
of the disease is from four to eight weeks. There are mild cases in which
the jaundice disappears within two weeks ; on the other hand, it may per-
sist for three months. The stools should be carefully watched, for they
give the first intimation of removal of the obstruction.
The diagnosis is rarely difficult. The onset in young, comparatively
healthy persons, the moderate grade of icterus, the absence of emaciation
or of evidences of cirrhosis or cancer, usually make the diagnosis easy.
Cases which persist for two and three months cause uneasiness, as the sus-
picion is aroused that it may be more than simple catarrh. The absence
of pain, the negative character of the physical examination, and the main-
tenance of the general nutrition are the points in favor of simple jaundice.
There are instances in which time alone can determine the true nature of
the case.
Treatment. — As a rule the patient can keep on his feet from the
outset. Measures should be used to allay the gastric catarrh, if it is pres-
ent. A dose of calomel may be given, and the bowels kept open subse-
quently by salines. The patient should not be violently purged. Bismuth
and bicarbonate of soda may be given, and the patient should drink freely
of the alkaline mineral waters, of which Vichy is the best. Irrigation of
the large bowel with cold water may be practised. The cold is supposed
to excite peristalsis of the gall-bladder and ducts, and thus aid in the ex-
pulsion of the mucus. This practice has been followed in my wards for
several years, but I cannot speak warmly of the results.
Cholelithiasis {Gall- Stories).
Calculi are formed in the gall-bladder. Evidence is wanting to show
that they are formed within the liver ducts, except in very rare instances.
They may be single, in which case the stone is usually ovoid and may at-
tain a very large size. Instances are on record of gall-stones measuring
more than five inches in length. They may be extremely numerous, rang-
ing from a score to several hundreds or even several thousands, in which
case the stones are very small. When moderately numerous, they show
signs of mutual pressure and have a polygonal form, with smooth facets ;
occasionally, however, five or six gall-stones of medium size are met with
in the bladder which are round or ovoid and without facets. They are
sometimes mulberry-shaped and very dark, consisting largely of bile-pig-
ment. Again there are small, black calculi, rough and irregular in shape,
and varying in size from sand to small shot. These are sometimes known
as gall-sand. On section, a calculus contains a nucleus, which consists
of bile-pigment, rarely a foreign body. The greater portion of the stone
is made up of cholesterin, which may form the entire calculus and is ar-
432 DISEASES OF THE DIGESTIVE SYSTEM.
ranged in concentric laminae showing also radiating lines. Salts of lime
and magnesia, bile acids, fatty acids, and traces of iron and copper are also
found in them. A majority of gall-stones consist of from seventy to
eighty per cent of cholesterin, in either the amorphous or the crystalline
form. As above stated, it is sometimes pure, but more commonly it is
mixed with the bile-pigment. The outer layer of the stone is usually
harder and brownish in color, and contains a larger proportion of lime
salts.
The mode of formation is by no means clear. A defect in the sodium
salts seems to favor the precipitation of the cholesterin and of the bile-
pigment. The lime exists in such slight quantities in the bile that it is
probably a pathological product of the mucous glands of the gall-bladder.
When the bile is retained long in the gall-bladder its concentration favors
the deposition.
Etiology.— Three fourths of the cases of gall-stones occur in women,
most frequently between the ages of thirty and sixty. Sedentary occupa-
tions, particularly when combined with overindulgence in eating, seem
important factors. The subjects are often stout, and usually very fond of
starchy and saccharine food. The conditions which induce lithic acid also
favor the development of gall-stones. Tight-lacing is regarded by Marchand
as an important factor in retarding the flow of the bile. Pregnancy has a
similar influence. Naunyn states that ninety per cent of women with
gall-stones have borne children. Constipation and depressing mental in-
fluences have been regarded as favoring circumstances.
Symptoms. — In a majority of the cases, gall-stones cause no symp-
toms. The gall-bladder will tolerate the presence of large numbers for an
indefinite period of time, and post-mortem examinations show that they
are present in twenty-five per cent of all women over sixty years of age
(Naunyn).
The eifects of gall-stones may be considered under the following head-
ings : The symptoms produced by the passage of a stone through the
ducts — biliary colic ; the effects of permanent plugging of the duct ; and
the more remote effects, due to ulceration and perforation, and the estab-
lishment of fistulae.
1. Biliary Colic. — It would appear that gall-stones may become en-
gaged in the cystic or the common duct without producing pain or
severe symptoms. More commonly the passage of a stone excites the
violent symptoms known as biliary colic. Tlie attack sets in abruptly
with agonizing pain in the right hypochondriac region, which radiates to
the shoulder, or is very intense in the epigastric and in the lower thoracic
regions. It is often associated with a rigor and a rise in temperature from
102° to 103°. The pain is usually so intense that the patient rolls about in
agony. There are vomiting, profuse sweating, and great depression of the
circulation. There may be marked tenderness in the region of the liver,
which may become enlarged. In a large number of the cases jaundice
DISEASES OF THE BILE-PASSAGES. 433
develops, but it is not a necessary symptom. Of course it does not occur
during the passage of the stone through the cystic duct, but only when it
becomes lodged in the common duct. Probably the intense pain is due to
the slow progress in the cystic duct, in which the stone takes a rotary
course owing to the arrangement of the Heisterian valve.
The attack varies in duration. It may last for a few hours, several
days, or even a week or more. If the stone becomes impacted in the
orifice of the common duct, the jaundice becomes intense ; much more
commonly it is a slight, transient icterus. The attack of colic may be re-
peated at intervals for some time, but finally the stone passes and the
symptoms rapidly disappear.
Occasionally accidents occur, such as rupture of the duct with fatal
peritonitis. Syncope, owing to the intensity of the pain, may follow and
has been known to prove fatal, and epilepsy has been seen. These are,
however, rare events. Palpitation and distress about the heart may be
present, and occasionally a mitral murmur develops during the paroxysm ;
but the cardiac conditions described by some writers as coming on acutely
in biliary colic are probably pre-existent in these patients.
The diagnosis of acute hepatic colic is generally easy. The pain is in
the upper abdominal and thoracic regions, whereas the pain in nephritic
colic is in the lower abdomen. A chill, with fever, is much more frequent
in biliary colic than in gastralgia, with which it is liable, at times, to be
confounded. A history of previous attacks is an important guide, and the
occurrence of jaundice, however slight, determines the diagnosis. To look
for the gall-stones, the stools should be thoroughly mixed with w^ater and
carefully filtered through a narrow-meshed sieve.
2. Chronic Obstruction of the Ducts by Gall-stones. — Of the Cystic
Duct. — The effects may be thus enumerated :
Dilatation of the gall-bladder — hydrops vesicae feller. This occurs
much more frequently than in obstruction of the common duct. The
fluid is almost invariably of a thin mucoid nature, though it may be
mixed with bile. In all cases, when the obstruction persists, the bile is
replaced by a clear fluid. This is an important point in diagnosis, par-
ticularly as a dropsical gall-bladder may form a very large tumor. The
reaction is not always constant. It is either alkaline or neutral ; the con-
sistence is thin and mucoid. Albumen is usually present. The organ
may reach an enormous size, and in one instance Tait found it occupying
the greater part of the abdomen. In such cases, as is not unnatural, it
has been mistaken for an ovarian tumor. In one of my cases it was
adherent to the broad ligament, and had been mistaken for a cyst of the
left ovary. The dilated gall-bladder can usually be felt below the edge of
the liver, and in many instances it has a characteristic outline like a
gourd. It usually projects directly downward, rarely to one side or the
other, though occasionally toward the middle line. It may reach below
the navel, and in persons with thin walls the outline can be accurately
434 DISEASES OF THE DIGESTIVE SYSTEM.
defined. It is to be remembered that distention of the gall-bladder may-
occur without jaundice ; indeed, the greatest enlargement has been met
with in such cases.
In obstruction of the common duct the gall-bladder is not necessarily
greatly enlarged. Occasionally it may be much distended without the
occurrence of any tumor which can be felt during life. In one case
(operation) eighteen ounces were removed from a gall-bladder, the edge
of which barely projected below the margin of the right lobe.
Acute phlegmonous cystitis. This is a rare event. Only seven in-
stances of it have been collected in the enormous statistics of Courvoi-
sier. In a case which I have reported the patient died on the fifth day
with symptoms of the most intense prostration, fever, and abdominal pain.
Perforation may occur with fatal peritonitis.
Suppurative cholecystitis, empyema of the gall-bladder, is much more
common, and in the great majority of cases is associated with gall-stones
— 41 in 55 cases (Courvoisier). There may be enormous dilatation, and
over a litre of pus has been found. Perforation and the formation of
abscesses in the neighborhood are not uncommon.
Calcification of the gall-bladder is commonly a termination of the pre-
vious condition. There are two separate forms, incrustation of the mucosa
with lime salts and the true infiltration of the wall with lime, the so-called
ossification. A remarkable example of the latter sent to me by Groves,
of Carp, is now in the McGill Medical Museum.
Atrophy of the gall-bladder. This is by no means uncommon. The
organ shrinks into a small fibroid mass, not larger, perhaps, than a good-
sized pea or walnut, or even has the form of a narrow fibrous string ;
more commonly the gall-bladder tightly embraces a stone. Tliis condition
is usually preceded by hydrops of tlie bladder. In an interesting case of
the kind, the patient, nearly twenty years before, had had an obscure
abdominal tumor, which caused so much difference of opinion among his
physicians that instruction was left in his will that the body should be
examined. The gall-bladder was entirely obliterated and closely encircled
a large gall-stone.
Occasionally the gall-bladder presents diverticula, which may be cut
oif from the main portion, and usually contain calculi.
Obstruction of the Common Duct.
The stone usually lies at the termination of the duct, just at the orifice
of the papilla, within a sort of pouch formed by the diverticulum of Vater.
Examined from the duodenum, it seems to be directly beneath the mu-
cosa. It is as a rule single ; but two and, in some instances, a series of
stones may occupy the entire duct. The effect of the obstruction is dila-
tation, with catarrhal or suppurative cholangitis.
(1) Obstruction, with catarrhal cholangitis.
The common duct may be as large as the thumb ; the hepatic duct and
its branches through the liver are greatly dilated, and the distention may
DISEASES OF THE BILE-PASSAGES. 435
even be apparent beneath the liver capsule. Great enlargement of the
gall-bladder is rare. The mucous membrane of the ducts may be smooth
and clear, and the contents a thin, colorless mucus.
Catarrhal cholangitis with gall-stones is characterized by a special
symptom group : {a) Ague-like paroxysms, chills, fever, and sweating ;
(b) jaundice of varying intensity, which persists for months or even years,
and deepens after each paroxysm ; (c) at the time of the paroxysms, pains
in the region of the liver with gastric disturbance. These symptoms may
continue on and off for three or four years, without the development of
suppurative cholangitis. In one of my cases the jaundice and recurring
hepatic intermittent fever existed from July, 1879, until August, 1882 ;
the patient recovered and still lives. The condition has lasted from eight
months to three years. The rigors are of intense severity, and the tem-
perature rises to 103° or 105°. The chills may recur daily for weeks, and
present a tertian or quartan type, so that they often are mistaken for
malaria, with which, however, they have no connection. The jaundice
is variable, and deepens after each paroxysm. Pain, which is sometimes
intense and colicky, does not always occur. There may be marked vomit-
ing and nausea. As a rule there is no progressive deterioration of health.
In the intervals between the attacks the temperature is normal.
The clinical history and the post-mortem examinations in my cases *
have shown conclusively that this condition may persist for years without
a trace of suppuration within the ducts.
The nature of the hepatic intermittent fever is not settled. Charcot
holds that it is due to the production of a ferment in the bile-passages,
and a bacillus, probably the hacteriwn coli commune^ has been found in
the ducts in several cases. Both Murchison and Ord hold that it is simply
due to local irritation of the mucous membrane, and that the fever is
really of a nervous character.
The effect upon the liver of chronic obstruction of the bile-duct is
very variable. The organ is rarely enlarged. It is firm and the con-
nective tissue is moderately increased. In none of my cases of persistent
obstruction by gall-stones was the liver greatly enlarged, nor did it present
macroscopically the features of cirrhosis. On this point my experience is
in accord with that of Sharkey, who has recently called in question the
statements of Charcot and Wickham Legg as to the occurrence of cirrhosis
under these circumstances.
(2) Obstruction, with suppurative cholangitis.
When suppurative cholangitis exists the mucosa is thickened, often
eroded or uh^erated ; there may be extensive suppuration in the ducts
throughout the liver, and even empyema of the gall-bladder. Occasionally
* On Fever of Hepatic Orip:in, particularly the Intermittent Pyrexia associated with
Gall-stones, .Johns Hopkins Hospital Reports, vol. ii, No. 1, 1890; and in Annals of
Surgery, 1890.
436 DISEASES OF THE DIGESTIVE SYSTEM.
the suppuration extends beyond the ducts, and there is localized liver
abscess, or there is perforation of the gall-bladder with the formation of
abscess between the liver and stomach.
Clinically it is characterized by a fever which may be intermittent, but
more commonly is remittent and without prolonged intervals of apyrexia.
The jaundice is rarely so intense, nor do we see the deepening of the color
after the paroxysms. There is usually greater enlargement of the liver
and tenderness and more definite signs of septicaemia. The cases run a
shorter course, and recovery never takes place.
3. The More Remote Effects of Gall-stones. — («) Biliary Fistulae.
These are not uncommon. There may, for instance, be abnormal com-
munication between the gall-bladder and the hepatic duct or the gall-
bladder and a cavity in the liver itself. More rarely perforation occurs
between the common duct and the portal vein. Of this there are at least
four instances on record, among them the celebrated case of Ignatius
Loyola. Perforation into the abdominal cavity is not uncommon; 119
cases exist in the literature (Courvoisier), in 70 of which the rupture
occurred directly into the peritoneal cavity ; in 49 there was encapsulated
abscess. Perforation may take place from an intrahepatic branch or
from the hepatic, common, or cystic ducts. Perforation from the gall-
bladder is the most common.
Fistulous communications between the bile-passages and the gastro-in-
testinal canal are frequent. Openings into the stomach are rare. Between
the duodenum and bile-passages they are much more common. Cour-
voisier has collected 10 instances of communication between the ductus
communis and the duodenum, and 73 cases between the gall-bladder and
the duodenum. Communication with the ileum and jejunum is extremely
rare. Of fistulous opening into the colon 39 cases are on record. These
communications can rarely be diagnosed ; they may be present without
any symptoms whatever. It is probably by ulceration into the duodenum
or colon that the large gall-stones escape.
Occasionally fistulous communication exists between the gall-bladder
and the urinary passages, and the stones may be found in the bladder.
The opening has been either into the pelvis of the kidney or, as has
been supposed, the gall-bladder has become adherent in the neighbor-
hood of the navel, and the stone has escaped through an open urachus.
It is possible that adhesions may form between the distended gall-bladder
and urinary bladder, since the former has been found adherent as low as
the broad ligament.
^lany instances are on record of fistulne between the l)ile-paRsages and
the lungs. Courvoisier has collected twenty-four cases. Bile may be
coughed up with the expectoration, sometimes in considerable quantities.
In only seven cases did recovery take place. In some of these the abscess
formation was due to hydatids, in some to ascarides. The perforation usu-
ally takes 'place through tlie lung, by a liver abscess communicating with
DISEASES OP THE BILE-PASSAGES. 437
the pleura, or occasionally the abscess enters the mediastinum and per-
forates a bronchus.
Of all fistulous communications the external or cutaneous is the most
common. Courvoisier's statistics number 184 cases, in fifty per cent of
which the perforation took place in the right hypochondrium ; in twenty-
nine per cent in the region of the navel. The number of stones dis-
charged varied from one or two to many hundreds. Recovery took place
in 78 cases ; some with, some without operation.
(b) Obstruction of the bowel by gall-stones. Eeference has already
been made to this, the frequency which appears from the fact that of 295
cases of obstruction, occurring during the past eight years, analyzed by
Fitz, 23 were by gall-stone. Courvoisier's statistics give a total number
of 131 cases, in six of which the calculi had a peculiar situation, as in a
diverticulum or in the appendix. Of the remaining 125 cases, in 70 the
stone was spontaneously passed, usually with severe symptoms. The post-
mortem reports show that in some of these cases even very large stones
have passed per viam naturalem^ as the gall-duct has been enormously dis-
tended, its orifice admitting the finger freely. This, however, is extremely
rare. The stones have been found most commonly in the ileum.
Other Affection^s of the Bile-ducts.
Cancer will be considered later.
Stenosis or complete occlusion may follow ulceration, most commonly
after the passage of a gall-stone. In these instances the obstruction is
usually situated low down in the common duct. Instances of this are
extremely rare. Foreign bodies, such as the seeds of various fruits, may
enter the duct, and occasionally round worms crawl into it. In the Wistar-
Horner Museum of the University of Pennsylvania there is a remarkable
specimen showing the common and hepatic ducts enormously distended
and densely packed with a dozen or more lumbricoid worms. A similar
specimen exists in one of the Paris museums. Liver-flukes and echino-
cocci are rare causes of obstruction in man.
Obstruction by pressure from without is more frequent. Naturally
cancer of the head of the pancreas is apt to involve the terminal portion
of the duct ; less often cancer of the pylorus. Secondary involvement
of the lymph glands of the liver is a common cause of occlusion of the
duct, and is met v,^ith in many cases of cancer of the stomach and other
abdominal organs. Kare causes of obstruction are aneurism of a branch cf
the cceliac axis or of the aorta, or pressure of very large abdominal tumors.
The symptoms produced are those of chronic obstructive jaundice.
At first, the liver is usually enlarged, but in chronic cases it may be re-
duced in size, and of a deeply bronzed color, and firm, owing to slight
increase in the connective tissue. The hepatic intermittent fever may be
associated with occlusion of the duct from any cause, but it is most fre-
438 DISEASES OF THE DIGESTIVE SYSTEM.
quently met with in chronic obstruction by gall-stones. Permanent occlu-
sion of the duct terminates in death. In a majority of the cases the con-
ditions which lead to the obstruction are in themselves fatal. Cases of
cicatricial occlusion may last for years. A patient under my care, who
was permanently jaundiced for nearly three years, had a fibroid occlusion
of the duct.
The diagnosis of the nature of the occlusion is often very difficult. A
history of colic, jaundice of varying intensity, paroxysms of pain, and in-
termittent fever point to gall-stones. In cancerous obstruction the tumor
mass can sometimes be felt in the epigastric region. In cases in which
the lymph glands in the transverse fissure are cancerous, the primary
disease may be in the pelvic organs or the rectum, or there may be a
limited cancer of the stomach, which has not given any symptoms. In
these cases the examination of the other lymphatic glands may be of
value. In a case, recently under observation, with jaundice of seven
weeks' duration, and believed to be catarrhal (as the patient's general con-
dition was good and he was said not to have lost flesh), a small nodular
mass was detected at the navel, which on removal proved to be scirrhus.
Involvement of the clavicular groups of lymph glands may also be service-
able in diagnosis. As already mentioned, the gall-bladder is often but
little enlarged in obstruction of the common duct. Great and progressive
enlargement of the liver with jaundice and moderate continued fever is
more commonly met with in cancer. In h3rpertrophic cirrhosis a similar
condition exists, but the organ is smooth and there is rarely progressive
enlargement while under observation.
Treatment of Gall-stones and their Effects. — In an attack
of biliary colic the patient should be kept under morphia, given h}^oder-
mically, in quarter-grain doses. In an agonizing paroxysm it is well to
give a whiif or two of chloroform until the morphia has had time to act.
Great relief is experienced from the hot bath and from fomentations in
the region of the liver. The patient should be given laxatives and should
drink copiously of alkaline mineral waters. Oli^e oil has proved useless
in my hands. When taken in large quantities, fatty concretions are passed
with tlie stools, which have been mistaken for calculi. Since -the days of
Durande, whose mixture of ether and turpentine is still largely used in
France, various remedies have been advised to dissolve the stones within
the gall-bladder, none of which are efficacious.
The diet should be regulated, the patient should take regular exercise
and avoid, as much as possible, the starchy and saccharine foods. The
soda salts recommended by Prout are believed to prevent the concentra-
tion of the bile and the formation of gall-stones. Either the sulphate or
the phosphate may be taken in doses of from one to two drachms daily.
Expression of gall-stones from the bladder by digital manipulation, as
recommended by George Ilarley, is a highly irrational procedure, not to
be followed. So long as gall-stones remain in the bladder they do little
DISEASES OF THE BILE-PASSAGES. 4P>9
or no harm in a great majority of cases. To force them on into the duct
is to render the patient liable to severe colic or to the still more seriou.-^
danger of permanent obstruction.
When tlie cystic duct is occluded and the gall-bladder distended, an
exploratory puncture may be made, as practised by the elder Pepper, in
1857, in a case of empyema of the gall-bladder, and by Bartholow in 1878.
The puncture may be made either to draw off fluid from a distended blad-
der or to explore for gall-stones. Aspiration is usually a safe procedure,
though a fatal result has followed. When the gall-bladder is distended
and plainly palpable, to sound for stones by an exploratory puncture is
justifiable, but under no other circumstances. " The easy and safe method
of sounding for impacted stones," recommended a few years ago by a Lon-
don physician, in which it is advised to thrust a sharp needle six inches
long between the navel and the margin of the liver, may be characterized
as one of the most extraordinary operations ever advocated, and would
probably always prove fatal, as in the case of the unhappy victim upon
whom it was practised.
The surgical treatment of gall-stones has of late 3^ears made rapid
progress. The operation of cholecystotomy, or opening the gall-bladder
and removing the stones, which was advised by Sims, has been remark-
ably successful, particularly in the hands of Lawson Tait. The removal
of the gall-bladder, cholecystectomy, has also been practised with success.
The indications for operation are : (a) Repeated attacks of gall-stone colic,
of great severity and danger, (b) The presence of a distended gall-bladder,
associated with attacks of pain or with fever. Many cases of obstruction
of the cystic duct with moderate distention of the gall-bladder produce
little or no inconvenience, and perfect recovery may take place with con-
traction and obliteration, (c) When a gall-stone is permanently lodged in
the common duct, and presents the group of symptoms above described.
It must, however, be borne in mind that, contrary to the experiences of
Charcot and other French writers, three of my cases recovered — one after
persistence of the condition for eight months, another for three years ; two
died of the effects of the prolonged jaundice, and two after operation.
The question, then, of advising removal in such cases should depend
largely upon the personal methods and success of the surgeon who is
available. The common duct has been explored and gall-stones removed
from it. The operation is necessarily much more serious and difficult
than that upon the gall-bladder.
440 DISEASES OF THE DIGESTIVE SYSTEM.
IV. CIRRHOSIS.
Definition. — A chronic disease of the liver, characterized by a gradual
destruction of liver-cells and an overgrowth of connective-tissue elements,
in consequence of which the organ becomes hard and usually small.
Etiology. — The disease occurs most frequently in middle-aged males.
It has been regarded as rare in children, except in the syphilitic form, but
Palmer Howard collected 63 cases, to which list Hatfield, in a further
search of the literature, has been able to add 93, so that its occurrence in
early life is more common than has been supposed.
The following are the recognized factors in inducing the disease : (a)
Alcohol — The abuse of spirits is the common cause. It is more frequent
in countries in which strong spirits are taken than in those in which malt
liquors and wines are used. The change results from the irritative effect
of the strong solution of alcohol absorbed from the stomach. The fusel
oil is thought to be the offending material. Similar effects are doubtless
produced by other substances, such as rich, highly seasoned foods, or, as
has been suggested, by ptomaines and other alkaloids.
(b) Syphilis. — We have already considered (under Syphilis) the forms
of cirrhosis, diffuse and gummatous, produced by this poison.
(c) Cyanotic Congestion. — In cases of chronic disease of the heart and
lungs the liver is in a condition of persistent venous h3rper£emia, in conse-
quence of which the central cells of the liver lobules atrophy and there is
hyperplasia of the connective tissue.
{d) Malaria. — Sclerosis of the liver may follow prolonged malarial
poisoning. In this country it is very rare.
(e) Tuherculosis. — We have already referred to the sclerotic changes in
the liver produced by tuberculosis. It rarely, if ever, induces a condition
which can be recognized clinically.
(/) Scarlet Fever. — The fact noted by Klein that in scarlet fever there
was an infiltration with small cells, an acute interstitial hepatitis, gives a
clew to the occurrence of some of the cases of cirrhosis of the liver in chil-
dren. In other infectious diseases, too, such as typhoid, there are localized
necrotic areas which must be replaced by connective tissue. In the cir-
rhosis of early life, excluding the alcoholic and syphilitic cases, the acute
infectious diseases are probably the important antecedents.
{g) Riclcets. — The enlargement of the liver in this disease is associated
with increase in the connective tissue, which surrounds the individual
lobules and produces changes in the bile-ducts (Ilodgben).
(//) Anthracosis. — It occasionally happens in coal-miners that the car-
bon pigment reaches the liver in large quantities, is deposited in the con-
nective tissue about the portal canal, and may lead to a variety of cirrhosis,
which has been described by Welch.
In animals, artificial obstruction of the bile-passages results in cirrhosis,
but in man there may be persistent stenosis of the common duct or ob-
CIRRHOSIS. 441
struction without marked increase in the connective tissue. The causes
whicli induce the cirrhosis which we meet at the bedside are alcohol and
syphilis.
Morbid Anatomy. — Practically on the post-mortem table we see
cirrhosis in four well-characterized forms :
(a) The At7^ophic Cirrhosis of Laennec. — The organ is greatly re-
duced in size and may be deformed. The weight is sometimes not more
than a pound or a pound and a half. It presents numerous granula-
tions on the surface ; is firm, hard, and cuts with great resistance. The
substance is seen to be made up of greenish-yellow islands, surrounded by
grayish-white connective tissue. This yellow appearance of the liver in-
duced Laennec to give it the name of cirrhosis.
{h) Fatty Cirrhosis. — Even in the atrophic form the fat is increased,
but in typical examples of this variety the organ is not reduced in size,
but is enlarged, smooth or very slightly granular, anasmic, yellowish white
in color, and resembles an ordinary fatty liver. It is, however, firm, cuts
with resistance, and microscopically shows a great increase in the connect-
ive tissue. This form is quite as common in this country as the atrophic
variety. It occurs most frequently in beer-drinkers.
(c) Hypertrophic Cirrhosis. — Enlargement of the liver occurs in the
early stage of the ordinary atrophic cirrhosis, but the increase is moderate
and largely due to h3rper8emia. The fatty cirrhotic liver is also large, and
may reach a hand's-breadth below the costal margin. The term h3rper-
trophic cirrhosis should be restricted to the form described by French
writers, which is also known as Mliary cirrhosis. Unfortunately, this has
been used by some writers to include as well the cases in which there hag
been permanent occlusion of the duct, either by stricture or a calculus j
the induration, however, is slight under these circumstances and hyper-
trophy very rare. It seems best to limit the terms hiliary and hypertrophic
cirrhosis to the form characterized by permanent enlargement of the liver,
a marked involvement of the smaller biliary canaliculi, and retention in
an unusual degree, in comparison with atrophic cirrhosis, of the number
and form of the liver-cells, in spite of the great increase of the lobular
connective tissue. In this form the liver is greatly enlarged ; in one of
my cases it weighed seven pounds. The surface is smooth, it is exceed-
ingly firm, resists cutting, and presents on section a deep greenish-yellow
color. All of my cases have been in hard drinkers.
(d) Perihepatitis ; Glissonian Cirrhosis. — In this form the liver is
greatly reduced in size, much altered in shape, and everywhere surrounded
by a firm grayish- white membrane, sometimes of semi-cartilaginous con-
sistence, varying from 10 to 15 mm. in thickness. This fibrous investment
can be stripped off readily, and the liver substance may look almost nor-
mal, but usually shows cirrhotic changes. The capsular thickening may
be slight, and the portal connective tissue chiefly involved. The capsule
of the si)leen is, as a rule, similarly affected, and both processes are asso-
29
442 DISEASES OF THE DIGESTIVE SYSTEM.
ciated with a proliferative peritonitis. The condition is most frequent as
a result of alcohol, but occurs also in instances of cyanotic induration.
The two essential elements in cirrhosis are destruction of liver-cells
and obstruction to the portal circulation.
In an autopsy on a case of atrophic cirrhosis the peritonaeum is usually
found to contain a large quantity of fluid, the membrane is opaque, and
there is chronic catarrh of the stomach and of the small intestines. The
kidneys are sometimes cirrhotic, the bases of the lungs may be much com-
pressed by the ascitic fluid, the heart often shows marked degeneration,
and arterio-sclerosis is usually present. A remarkable feature is the asso-
ciation of acute tuberculosis with cirrhosis. In seven cases of my series
the patients died with either acute tuberculous peritonitis or acute tuber-
culous pleurisy. Pitt states that twenty-two and a half per cent of the
cases of cirrhosis dying in Guy's Hospital during twelve years had acute
tuberculosis.
The compensatory circulation is usually readily demonstrated. It is
carried out by the following set of vessels : (1) The accessory portal system
of Sappey, of which important branches pass in the round and suspensory
ligaments and unite w^th the epigastric and mammary systems. These
vessels are numerous and small. Occasionally a large single vein, which
may attain the size of the little finger, passes from the hilus of the liver in
the round ligament, and joins the epigastric veins at the navel. Although
this has the position of the umbilical vein, it is usually, as Sappey showed,
a para-umbilical vein — that is, an enlarged vein by the side of the obliter-
ated umbilical vessel. There may be produced about the navel a large
bunch of varices, the so-called caput Medusae. Other branches of this
system occur in the gastro-epiploic omentum, about the gall-bladder, and,
most important of all, in the suspensory ligament. These latter form
large branches, which anastomose freely with the diaphragmatic veins, and
so unite with the vena azygos. (2) By the anastomosis between the oesoph-
ageal and gastric veins. The veins at the lower end of the oesophagus
may be enormously enlarged, producing varices which project on the
mucous membrane. (3) The communications between the h3emorrhoidal
and the inferior mesenteric veins. The freedom of communication in this
direction is very variable, and in some instances the hsemorrhoidal veins
are not much enlarged. (4) The veins of Retzius, which unite the radicles
of the portal branches in the intestines and mesentery with the inferior
vena cava and its branches. To this system belong the whole group of
retroperitoneal veins, which are in most instances enormously enlarged,
particularly about the kidneys, and which serve to carry off a considerable
proportion of the portal blood.
Sjnnptoms. — (n) Of the Atrophic Form. — The most extreme grade of
atrophic cirrhosis may exist without symptoms. So long as the compen-
satory circulation is maintained the patient may suffer little or no incon-
venience. The remarkable efficiency of this collateral circulation is well
CIRRHOSIS. 443
seen in those rare instances of permanent obliteration of the portal vein,
which may exist for many years.
The symptoms may be divided into two groups — obstructive and toxic.
Obstructive. — The overfilling of the blood-vessels of the stomach and
intestine leads to chronic catarrh, and the patients suffer with nausea
and vomiting, particularly in the morning ; the tongue is furred and the
bowels are irregular. Haemorrhage from the stomach may be an early
symptom ; it is often profuse and liable to recur. It seldom proves fatal.
The amount vomited may be remarkable, as in a case already referred to,
in which ten pounds were ejected in seven days. Following the haemate-
mesis melaena is common. Enlargement of the spleen occurs from the
chronic congestion. The organ can usually be felt. Evidences of the
establishment of the collateral circulation are seen in the enlarged epigas-
tric and mammary veins, more rarely in the presence of the caput Medusae
and in the development of haemorrhoids. The distended venules in the
lower thoracic zone along the line of attachment of the diaphragm are not
specially marked in cirrhosis. The most striking feature of failure in the
compensatory circulation is ascites, the effusion of serous fluid into the
peritoneal cavity. The conditions under which this occurs are still ob-
scure. The abdomen gradually distends, may reach a large size, and con-
tain as much as 15 or 20 litres. (Edema of the feet may precede or develop
with the ascites. The dropsy rarely becomes general.
Jaundice is usually slight, and was present in only 35 of 130 cases of
cirrhosis reported by Fagge. The skin has frequently a sallow, slightly
icteroid tint. The urine is often reduced in amount, contains urates in
abundance, often a slight amount of albumen, and, if jaundice is intense,
tube-casts. The disease may be afebrile throughout, but in many cases,
as shown by Carrington, there is slight fever, from 100° to 102*5°.
Examination in the early stage of the disease may show moderate en-
largement of the liver, which may be painful on pressure. At this period
the patient may come under observation for dyspepsia, haematemesis, slight
jaundice, or nervous symptoms. Later in the disease, the patient has an
unmistakable hepatic facies ; he is thin, the eyes are sunken, the conjunc-
tivae watery, the nose and cheeks show distended venules, and the complex-
ion is muddy or icteroid. On the enlarged abdomen the vessels are dis-
tended, and a bunch of dilated veins may surround the navel. When
much fluid is in the peritonaeum it is impossible to make a satisfactory ex-
amination, but after withdrawal the area of liver dulness is found to be
diminished, particularly in the middle line, and on deep pressure the edge
of the liver can be detected, and occasionally the hard, firm, and even
granular surface. The spleen can be felt in the left hypochondriac region.
Examination of the anus may reveal the presence of haemorrhoids.
Toxic Symptoms. — At any stage of atrophic cirrhosis the patient may
develop cerebral symptoms, either a noisy, joyous delirium, or stupor,
coma, or even convulsions. The condition is not infrequently mistaken for
444 DISEASES OF THE DIGESTIVE SYSTEM.
uraBmia. The nature of the toxic agent is not yet settled. The symptoms
may develop without jaundice, and cannot be attributed to cholaemia, and
they may come on in hospital when the patient has not had alcohol for
weeks.
The fatty cirrhotic liver may produce symptoms similar to those of the
atrophic form, but it more frequently is latent and is found accidentally
in topers who have died from various diseases. The greater number of
the cases clinically diagnosed as cirrhosis with enlargement come in this
division.
(b) Hypertrophic or biliary cirrhosis has a definite and distinctive
symptomatology. The liver may be enlarged for months or even years.
Jaundice persists for some time, on which point French writers lay great
stress. It may, however, come on acutely with the other symptoms. It
is intense, like an obstructive jaundice, but, as a rule, the stools are bile-
stained. It may continue for a long time without the development of
other symptoms; then delirium sets in and all the features of an acute
febrile jaundice. The tongue is dry, the pulse rapid, the temperature
ranges from 102° to 104°, and petechiae occur on the skin. The patient
may present every feature of acute yellow atrophy, including even the
convulsive seizures. The attack in one of my cases proved fatal within
ten days ; in another it was prolonged for three weeks. Ascites does not
develop. The enlargement of the liver may be the sole diagnostic crite-
rion between these cases and acute yellow atrophy. I do not know, how-
ever, of the occurrence of lencin or tyrosin in the urine in this condition.
(c) The perihepatitis with cirrhosis cannot be distinguished from the
ordinary atrophic form.
Diagnosis. — With ascites, a well-marked history of alcoholism, the
hepatic facies, and haemorrhage from the stomach or bowels, the diag-
nosis is rarely doubtful. If, after withdrawal of the fluid, the spleen is
found to be enlarged and the liver either not palpable or, if it is en-
larged, hard and regular, the probabilities in favor of cirrhosis are very
great. In the early stages of the disease, when the liver is increased in
size, it may be impossible to say whether it is a cirrhotic or a fatty liver.
The differential diagnosis between common and syphilitic cirrhosis can
sometimes be made. A marked history of syphilis or the existence of
other syphilitic lesions, with great irregularity in the surface or at the
edge of the liver, are the points in favor of the latter. Thrombosis or
obliteration of the portal vein can rarely be differentiated In the case of
fibroid transformation of the portal vein which came under my observa-
tion, tlie collateral circulation had been established for years, and the
symptoms were simply those of extreme portal obstruction, such as occur
in cirrhosis. Thrombosis of the portal vein is frequent in cirrhosis and
may be characterized by a rapidly developing ascites.
Prognosis. — The prognosis is, as a rule, bad. When the collateral
circulation is fully established the patient may have no symptoms what-
ciRnnosis. 445
ever. Three cases of advanced atrophic cirrhosis have died under my ob-
servation of other aifections without presenting during life any symptoms
pointing to disease of the liver. There are instances, too, of enlargement
of the liver, slight jaundice, cerebral symptoms, and even haematemesis, in
which the liver becomes reduced in size, the symptoms disappear, and the
patient may live in comparative comfort for many years. There are many
cases, too, in which, after one or two tappings, the symptoms have disap-
peared and the patients have apparently recovered.
Treatment. — Ordinary cirrhosis of the liver is an incurable disease.
Many writers, speaking of the curability of certain forms, show a lack of
appreciation of the essential conditions upon which the symptoms depend.
So far as we have any knowledge, no remedies at our disposal can alter or
remove the cicatricial connective tissue which constitutes the materia
peccans in ordinary cirrhosis. On the other hand, we know that extreme
grades of contraction of the liver may persist for years without symptoms
when the compensatory circulation exists. The so-called cure of cirrhosis
means the re-establishment of this compensation ; and it w^ould be as un-
reasonable to speak of healing a chronic valvular lesion when w4th digi-
talis we have restored the circulatory balance as it is to speak of curing
cirrhosis of the liver when by tapping and other measures the compensa-
tion has in some way been restored.
The patient should abstain entirely from alcohol, and, if possible, should
take a milk diet, which has been highly recommended by Semmola. In
any case, the diet should be nutritious, but not too rich. Measures should
be employed to reduce the gastro-intestinal catarrh, and the patient should
lead a quiet, out-of-door life and keep the skin active, the bowels regular,
and the urine abundant. In non-syphilitic cases it is useless to give either
mercury or iodide of potassium. When a well-marked history of syphilis
exists these remedies should be used, but neither of them has any more
influence upon the development of a new growth of connective tissue in
the liver than it has upon the progressive development of a scar tissue in
a keloid or in an ordinary developing cicatrix. The ascites should be
tapped early, and the operation may be repeated so soon as the distention
becomes distressing. The continuous drainage with a Southey's tube may
be employed. It is much better to resort to tapping early if after a few
days' trial the fluid does not subside rapidly under the use of saline purges.
From half an ounce to an ounce and a half of sulphate of magnesia may
be given in as little water as possible half an hour before breakfast. Elate-
rium, the compound jalap powder, or the bitartrate of potash may also be
employed. Digitalis and squills are often useful. In the syphilitic cases
or when syphilis is suspected iodide of potassium may be given in doses of
from fifteen to thirty drops of the saturated solution three times a day,
and mercury, which is conveniently given with squills and digitalis in the
form of Addison's or Niemeyer's pill. A case of well-marked syphilitic
cirrhosis with recurring ascites, in which tapping was resorted to on eight
446 DISEASES OF THE DIGESTIVE SYSTEM.
or ten occasions, took tliis pill at intervals for a year with the greatest bene-
fit, and subsequently had four years of tolerably good health.
V. ABSCESS OF THE LIVER.
Etiology. — Suppuration within the liver, either in the parenchyma
or in the blood or bile passages, occurs under the following conditions :
(1) The tropical abscess. In hot climates this form may develop idio-
pathically, but more commonly follows dysentery. It frequently occurs
among Europeans in India, particularly those who drink alcohol freely and
are exposed to great heat. The relation of this form of abscess to dysen-
tery is still under discussion, and Anglo-Indian practitioners are by no
means unanimous on the subject. Certainly cases may develop without
a history of previous dysentery, and there have been fatal cases without
any affection of the large bowel. In this country the large solitary tropi-
cal abscess also occurs, oftenest in the Southern States. In Baltimore it
is not very infrequent, as may be judged from the fact that during two
years there have been at my clinic five cases, and I know of the occurrence
of three or four additional cases during this time in the city.
The relation of this form of abscess to the amoela coli has been care-
fully studied by Kartulis and exhaustively considered in a monograph by
Councilman and Lafleur. The descriptions and illustrations of these
authors are most convincing as to the direct etiological association of this
organism with liver abscess. Clinically the patient may have amoeba coli
in the stools and well-marked signs of liver abscess without marked symp-
toms of dysentery and even with the faeces well formed.
(2) Traumatism is an occasional cause. The injury is generally in the
hepatic region. Two instances have come under my notice of it in brake-
men who were injured while coupling cars. Injury of the head is not in-
frequently followed by liver abscess.
(3) Embolic or pysemic abscesses are the most numerous, and may de-
velop in a general pyaemia from any cause or follow foci of suppuration in
the territory of the portal vessels. The infective agents may reach the
liver through the hepatic artery, as in those cases in which the original
focus of infection is in the area of the systemic circulation ; though it may
happen occasionally that tlie infective agent, instead of passing through
the lungs, reaches the liver through the inferior vena cava and the hepatic
veins. A remarkable instance of multiple abscesses of arterial origin was
afforded by the case of aneurism of the hepatic artery reported by Ross
and myself. Infection through the portal vein is much more common.
It results from dysentery and other ulcerative affections of the bowels,
appendicitis, occasionally after typhoid fever, in rectal affections, and in
abscesses in the pelvis. In these cases the abscesses are multiple and, as a
rule, within the branches of the portal vein — suppurative pylephlebitis.
ABSCESS OF THE LIVER. 447
(4) A not uncommon cause of suppuration is inflammation of the bile-
passages caused by gall-stones, more rarely by parasites — suppurative cho-
langitis.
In some instances of tuberculosis of the liver the affection is chiefly of
the bile-ducts, with the formation of multiple tuberculous abscesses con-
taining a bile-stained pus.
(5) Foreign bodies and parasites. In rare instances foreign bodies^
such as a needle, may pass from the stomach or gullet, lodge in the liver,
and excite an abscess, or, as in several instances which have been reported,
a foreign body, such as a needle or a fish-bone, may perforate a branch or
the portal vein itself and induce extensive pylephlebitis. Echinococcus
cysts frequently cause suppuration ; the penetration of round worms into
the liver less commonly ; and most rarely of all the liver-fluke.
Morbid Anatomy. — (a) Of the Solitary or Tropical Abscess. — This
is not always single ; there may be two or even more large abscess cavities,
ranging in size from an orange to a child's head. The largest-sized ab-
scess may contain from three to six litres of pus and involve more than
three fourths of the entire organ. In Waring's statistics, sixty-two per
cent of the cases were single. The abscess in nearly seventy per cent of
the cases was in the right lobe, more toward the convexity than the con-
cave side. In long-standing cases the abscess-wall may be firm and thick,
but, as a rule, the cavity possesses no definite limiting membrane, and sec-
tion of the wall shows an internal layer, grayish in color, shreddy, and
made up of necrotic liver substance, pus-cells, and amoebae ; a middle
layer, brownish red in color ; and an external zone of hyperaemic liver tis-
sue. The pus is often reddish brown in color, closely resembling anchovy
sauce. In other instances it is grayish white, mucoid, and may be quite
creamy. The odor is at times very peculiar. In one instance it had the
sour smell of chyme, though no connection with the stomach was found.
In a recent case of amoebic dysentery there were multiple miliary abscesses
in the liver, all of which contained amoebae.
The bacteriological examination of the contents show that as a rule
the pus is sterile (Kartulis). The termination of this form of abscess may
be as follows, as noted in Waring's 300 cases : Kemained intact, fifty-six
per cent ; opened by operation, sixteen per cent ; perforated the right
pleura, nearly five per cent ; ruptured into the right lung, nine per cent ;
ruptured into the peritonaeum, five per cent ; ruptured into the colon,
nearly three per cent ; and there were in addition instances which rupt-
ured into the hepatic and bile-vessels and into the gall-bladder.
{h) Of Septic and Pymmic Abscesses. — These are always multiple,
though occasionally, following injury, there may be a large solitary collec-
tion of pus.
In suppurative pylephlebitis the liver is uniformly enlarged. The cap-
sule may be smooth and the external surface of the organ of normal
appearance. In other instances, numerous yellowish -white points appear
448 DISEASES OF THE DIGESTIVE SYSTEM.
beneath the capsule. On section there are isolated pockets of pus, either
having a round outline or in some places distinctly dendritic, and from
these the pus may be squeezed. They look like small, solitary abscesses,
but, on probing, are found to communicate with the portal vein and to
represent its branches, distended and suppurating. The entire portal sys-
tem within the liver may be involved ; sometimes territories are cut off by
thrombi. The suppuration may extend into the main branch or even into
the mesenteric and gastric veins. The pus may be fetid and is often bile-
stained ; it may, however, be thick, tenacious, and laudable. In suppura-
tive cholangitis there is usually obstruction by gall-stones, the ducts are
greatly distended, the gall-bladder enlarged and full of pus, and the
branches within the liver are extremely distended, so that on section there
is an appearance not unlike that described in pylephlebitis.
Suppuration about echinococcus cysts may be very extensive, forming
enormous abscesses, the characters of which are at once recognized by the
remnants of the cysts.
Symptoms. — («) Of the Large Solitary Abscess. — In the tropics
there are instances in which the abscess appears to be latent and to run a
course without definite symptoms, and death may occur suddenly from
rupture.
Fever, pain, enlargement of the liver, and the development of a septic
condition are the important symptoms of hepatic abscess. The tempera-
ture is elevated at the outset and is of an intermittent or septic type. It
is irregular, and may remain normal or even subnormal for a few days ;
then the patient has a rigor and the temperature rises to 103° or higher.
Owing to this intermittent character of the fever the cases are usually, in
this latitude, mistaken for malaria. The fever may rise every afternoon
without a rigor. Profuse sweating is common, particularly when the
patient falls asleep. In chronic cases there may be little or no fever. At
the time of writing, there is in one of my wards a patient with liver
abscess which has perforated the lung who still coughs up pus, but
whose temperature has been normal for weeks. The pain is variable, and
is usually referred to the back or shoulder ; or there is a dull aching sen-
sation in the right hypochondrium. When turned on the left side, the
patient often complains of a heavy, dragging sensation, so that he usually
prefers to lie on the right side ; at least, this has been the case in a major-
ity of the instances which have come under my observation. Pain on
pressure over the liver is usually present, particularly deep pressure at the
costal margin in the nipple line.
The enlargement of the liver is most marked in the right lobe, and, as
the abscess cavity is usually situated more toward the up2:)er than the un-
der surface, the increase in volume is upward and to the right, not down-
ward, as in cancer and the other affections producing enlargement. Per-
cussion in the mid-sternal and parasternal lines may show a normal limit.
At the nipple-line the curve of liver dulness begins to rise, and in the mid-
ABSCESS OF THE LIVER. 449
axillary it may reach the fifth rib, Avhile behind, near the sj^jine, the area
of dulness may be almost on a level with the angle of the scapula. Of
course there are instances in which this characteristic feature is not pres-
ent, as when the abscess occupies the left lobe. The enlargement of the
liver may be so great as to cause bulging of the right side, and the edge
may project a hand's-breadth or more below the costal margin. In such
instances the surface is smooth. Palpation is painful, and there may be
fremitus on deep inspiration. In some instances fluctuation may be de-
tected. Adhesions may form to the abdominal wall and the abscess may
point below the margin of the ribs, or even in the epigastric region. In
many cases the aj^pearance of the patient is suggestive. The skin has a
sallow, slightly icteroid tint, the face is pale, the complexion muddy, the
conjunctivae are infiltrated, and often slightly bile-tinged. There is in the
facies and in the general appearance of the patient a strong suggestion of
the existence of abscess. There is no internal affection associated with
suppuration which gives, I think, just the same hue as certain instances
of abscess of the liver. Marked jaundice is rare. Diarrhoea may be present
and may give an important clew to the nature of the case, particularly if
amoebae are found in the stools. Constipation may occur.
Eemarkable and characteristic symptoms arise when the abscess in-
vades the lung. The extension may occur through the diaphragm, with-
out actual rupture, and with the production of a purulent pleurisy and
invasion of the lung. In four cases of this kind, Avhich have been under
observation recently, the patients gradually developed a severe cough,
usually of an aggravated and convulsive character, there were signs of in-
volvement at the base of the right lung, defective resonance, feeble tubular
breathing, and increase in the tactile fremitus ; but the most characteristic
feature was the presence of a reddish-brown expectoration of a brick-dust
color, resembling anchovy sauce. This, which was noted originally by
Budd, was present in our cases, and in addition Reese and Lafleur found
in all ammhce coli identical with those which exist in the liver abscess and
in the stools. They are present in variable numbers and display active
amoebic movements. The brownish tint of the expectoration is due to
blood-pigment and blood-corpuscles, and there may be orange-red crystals
of haematoidin.
The abscess may perforate externally, as mentioned already, or into the
stomach or bowel ; occasionally into the pericardium. The duration of
this form is very variable. It may run its course and prove fatal in six
or eight weeks or may persist for several years.
The prognosis is serious, as the mortality is more than fifty per cent.
The death-rate has been lowered of late years, owing to the greater fear-
lessness with which surgeons now attack these cases.
{h) Of the Pymmic Abscess and Suppurative Pylephlehitis. — Clinically
these conditions cannot be separated. Occurring in a general pyaemia,
no special features may be added to the case. When there is suppuration
450 DISEASES OF THE DIGESTIVE SYSTEM.
within the portal vein the liver is uniformly enlarged and tender, though
pain may not be a marked feature. There is an irregular, septic fever,
and the complexion is muddy, sometimes distinctly icteroid. The features
are indeed those of pyaemia, plus a slight icteroid tinge, and an enlarged
and painful liver. The latter features alone are peculiar. The sweats,
chills, prostration, and fever have nothing distinctive.
Diagnosis. — Abscess of the liver may be confounded with intermit-
tent fever, a common mistake in malarial regions. Practically an inter-
mittent fever which resists quinine is not malarial. Laveran's organisms
are also absent from the blood. When the abscess bursts into the pleura
a right-sided empyema is produced and perforation of the lung usually
follows. When the liver abscess has been latent and dysenteric symptoms
not marked, the condition may be considered empyema or abscess of the
lung. In such cases the anchovy-sauce-like color of the pus and the
presence of the amcebas will enable one to make a definite diagnosis, as
has been done in cases by Lafleur. Perforation externally is readily recog-
nized, and yet in an abscess cavity in the epigastric region it may be difficult
to say whether it has proceeded from the liver or is in the abdominal wall.
When the abscess is large, and the adhesions are so firm that the liver
does not descend during inspiration, the exploratory needle does not make
an up-and-down movement during aspiration. In an instance of this
kind which I saw with Hearn at the Philadelphia Hospital, all the feat-
ures, local and general, seemed to point to abscess in the abdominal wall,
but the operation revealed a large perforating abscess cavity in the left
lobe of the liver. The diagnosis of suppurating echinococcus cyst is
rarely possible, except in Australia and Iceland, where hydatids are so
common. In the only case which has come under my observation, the in-
numerable tumors scattered throughout the abdomen and the great size of
the liver led, not unnaturally, in spite of the occurrence of septic symp-
toms, to the diagnosis of cancer.
Perhaps the most important aifection from which suppuration within^
the liver is to be separated is the intermittent hepatic fever associated with
gall-stones. Of the cases reported a majority have been considered due to
suppuration, and in two of my cases the liver had been repeatedly aspirated.
Post-mortem examinations have shown conclusively that the high fever
and chills may recur at intervals for years without suppuration in the
ducts. The distinctive features of this condition are paroxysms of fever
with rigors and sweats — which may occur with great regularity, but which
more often are separated by long intervals — the deepening of the jaundice
after the paroxysms, the entire apyrexia in the intervals, and the mainte-
nance of the general nutrition. The time element also is important, as in
some of these cases tlie disease has lasted for several years. Finally, it is
to be remembered that abscess of the liver, in temperate climates at least,
is invariably secondary, and the primary source must be carefully sought
for, either in dysentery, sliglit ulceration of the rectum, suppurating
NEW GROWTHS IN THE LIVER. 451
haemorrhoids, ulcer of tlie stomach, or in suppurative diseases of otlier
parts of the body, particularly in the skull or in the bones.
In suspected cases, whether the liver is enlarged or not, exploratory
aspiration may be performed withou.t risk. The needle may be entered in
the anterior axillary line in the lowest interspace, or in the seventh inter-
space in the mid-axillary line, or over the centre of the area of dulness
behind. The patient should be placed under ether, for it may be neces-
sary to make several deep punctures. It is not well to use too small an
aspirator. No ill effects follow this procedure, even though blood may
leak into the peritoneal cavity. Extensive suppuration may exist, and yet
be missed in the aspiration, particularly when the branches of the portal
vein are distended with pus.
Treatment. — Pysemic abscesses and suppurative pylephlebitis are in-
variably fatal. Surgical measures are not justified in these cases, unless an
abscess shows signs of pointing As the abscesses associated with dysentery
are often single, they afford a reasonable hope for operation. If, however,
the patient is expectorating the pus, if the general condition is good and
the hectic fever not marked, it is best to defer operation, as many of these
instances recover spontaneously. The large single abscesses offer the best
chance for operation.
The general medical treatment of the cases is that of ordinary septi-
caemia.*
VI. NEW GROWTHS IN THE LIVER.
These may be cancer, either primary or secondary, sarcoma, or an-
gioma.
Etiology. — Cancer of the liver is third in order of frequency of in-
ternal cancer. It is rarely primary, usually secondary to cancer in other
organs. It is a disease of late adult life. According to Leichtenstern,
over fifty per cent of the cases occur between the fortieth and the sixtieth
years. It occasionally occurs in children. Women are attacked less fre-
quently than men. It is stated by some authors that secondary cancer is
more common in women, owing to the frequency of cancer of the uterus.
Heredity is believed to have an influence in from fifteen to twenty per
cent.
In many cases trauma is an antecedent, and cancer of the bile-passages
is associated in many cases with gall-stones. Cancer is stated to be less
common in the tropics. Its relative proportion to other diseases may be
judged from the fact that among the first three thousand patients admit-
ted to the wards of the Johns Hopkins Hospital there were seven cases of
cancer of the liver.
* For gonnral rules and the modern surgical treatment of the condition, the reader
is referred to Godlee's lectures, British Medical Journal, vol. i, 1890.
452 DISEASES OP THE DIGESTIVE SYSTEM.
Morbid Anatomy. — The following forms of new growths occur in
the liver and have a clinical importance :
Cancer. — (1) Primary cancer^ of which three forms may be recog-
nized.*
[a) The massive cancer^ which causes great enlargement and on section
shows a uniform mass of new growth, which occupies a large portion cf
the organ. It is grayish white, usually not softened, and is abruptly out-
lined from the contiguous liver substance.
{h) Nodular cancer^ in which the liver is occupied by nodular masses,
some large, some small, irregularly scattered throughout the organ. Usu-
ally in one region there is a larger, perhaps firmer, older-looking mass,
which indicates the primary seat, and the numerous nodules are secondary
to it. This form is much like the secondary cancerous involvement, ex-
cept that it seldom reaches a large size.
(c) The third is the remarkable and rare variety, cancer with cirrhosis^
which forms an anatomical picture perfectly unique and at first very
puzzling. The liver is not much enlarged, rarely weighing more than two
and a half or three kilogrammes. The surface is grayish yellow, studded
over with nodular yellowish masses, resembling the projections in an ordi-
nary cirrhotic liver. On section the cancerous nodules are seen scattered
throughout the entire organ, varying in diameter from three to ten or
more millimetres and surrounded with fibrous tissue.
Histologically, the primary cancers are epitheliomata — alveolar and
trabecular. The character of the cells varies greatly. Some varieties are
polymorphous ; others small polyhedral ; and others again contain giant
cells. In rare instances, as in one described by Greenfield, the cells are
cylindrical. The trabecular form of epithelioma is also known as adenoma
or adeno-carcinoma.
(2) Secondary Cancer. — The organ is usually enormously enlarged,
and may weigh twenty pounds or more. The cancerous nodules project
beneath the capsule, and can be felt during life or even seen through the
thin abdominal walls. They are usually disseminated equally, though in
rare instances they may be confined to one lobe. The consistence of the
nodules varies ; in some cases they are firm and hard and those on the
surface show a distinct umbilication, due to the shrinking of the fibrous
tissue in the centre. These superficial cancerous masses are still some-
times spoken of as " Farre's tubercles." More frequently the masses are
on section grayish white in color, or hcTmorrhagic. Kupture of blood-
vessels is not uncommon in these cases. In one specimen there was an
enormous clot beneath the capsule of the liver, together with haemorrhage
into the gall-bladder and into the peritonaeum. The secondary cancer
shows the same structure as the initial lesion, and is usually either an alve-
olar or cylindrical carcinoma. Degeneration is common in these second-
* Ilanot and Gilbert, fitudes sur les Maladies du Foie, Paris, 1888.
NEW GROWTHS IN THE LIVER. 453
ary growtlis ; thus the hyaline transformation may convert large areas into
a dense, dry, grayish-yellow mass. Extensive areas of fatty degeneration
may occur, sclerosis is not uncommon, and haemorrhages are frequent.
Suppuration sometimes follows.
(3) Cancer of the Bile- Passages-. — Much attention has been given to
this of late, and both Zenker and Musser have recently published ex-
haustive papers on the subject. In 100 cases collected by Musser the
large proportion (3 to 1) were in females. Jaundice was present in sixty-
nine per cent, and in about the same percentage there was a tumor in the
region of the gall-bladder. Courvoisier has collected 100 cases, of which
83 were in men and 17 in women. The association of cancer of the bile-
passages with calculi has long been recognized, and they are present in at
least seven eighths of all cases. The fundus of the gall-bladder is usually
involved first. The process may extend to the common or hepatic ducts,
and invasion of the contiguous structures is common. The ducts may be
aifected primarily.
Sarcoma. — Of primary sarcoma of the liver very few cases have been
reported. Secondary sarcoma is more frequent, and many examples of
lympho-sarcoma and myxo-sarcoma are on record, less frequently glio-
sarcoma or the smooth or striped myoma.
The most important form is the melano-sarcoma, which develops in
the liver secondarily to sarcoma of the eye or of the skin. Very rarely
melano-sarcoma develops primarily in the liver. Of the reported cases
Hanot excludes all but one. In this form the liver is greatly enlarged, is
either uniformly infiltrated with the cancer, which gives the cut surface
the appearance of dark granite, or there are large nodular masses of a
deep black or marbled color. There are usually extensive metastases, and
in some instances every organ of the body is involved. Nodules of melano-
sarcoma of the skin may give a clew to the diagnosis.
Other Forms of Liver Tumor. — One of the commonest tumors in the
liver is the angioma, which occurs as a small, reddish body the size of a
walnut, and consists simply of a series of dilated vessels. Occasionally in
children angiomata have developed and produced large tumors.
Cysts are occasionally found in the liver, either single, which are not
very uncommon, or multiple, when they usually coexist with congenital
cystic kidneys.
Symptoms. — It is often impossible to differentiate primary and sec-
ondary cancer of the liver unless the primary seat of the disease is evident,
as in the case of scirrhus of tlie breast, or cancer of the rectum, or of a
tumor in the stomach, which can be felt. As a rule, cancer of the liver is
associated with progressive enlargement ; but there are cases of primary
nodular cancer, and in the cancer with cirrhosis the organ may not be
enlarged. Gastric disturbance, loss of appetite, nausea, and vomiting are
frequent. Progressive loss of flesh and strengtli may be the first symp-
toms. Pain or a sensation of uneasiness in the right hypochondriac region
454 DISEASES OF THE DIGESTIVE SYSTEM.
may be present, but enormous enlargement of the liver may occur without
the slightest pain. Jaundice, which is present in at least one half of the
cases, is usually of moderate extent, unless the common duct is occluded.
Ascites is rare, except in the form of cancer with cirrhosis, in which the
clinical picture is that of the atrophic form. Pressure by nodules on the
portal vein or extension of the cancer to the peritonaeum may also induce
ascites.
Inspection shows the abdomen to be distended, particularly in the
upper zone. In late stages of the disease, when emaciation is marked,
the cancerous nodules can be plainly seen beneath the skin, and in rare
instances even the umbilications. The superficial veins are enlarged. On
palpation the liver is felt, a hand's-breadth or more below the costal margin,
descending with each inspiration. The surface is usually irregular, and
may present large masses or smaller nodular bodies, either rounded or
with central depressions. In instances of diffuse infiltration the liver may
be greatly enlarged and present a perfectly smooth surface. The growth
is progressive, and the edge of the liver may ultimately extend below the
level of the navel. Although generally uniform and producing enlarge-
ment of the whole organ, occasionally, when the tumor develops from the
left lobe, it may form a solid mass, which occupies the epigastric region.
By percussion the outline can be accurately limited and the progressive
growth of tumor estimated. The spleen is rarely enlarged. Pyrexia is
present in many cases, usually a continuous fever, ranging from 100° to
102° ; it may be intermittent with rigors. This may be associated with
the cancer alone, or, as in one of my cases, with suppuration. CEdema of
the feet, from anemia, usually supervenes. Cancer of the liver kills in
from three to fifteen months.
Diagnosis. — The diagnosis is easy when the liver is greatly enlarged
and the surface nodular. The smoother forms of diffuse carcinoma may
at first be mistaken for fatty or amyloid liver, but the presence of jaun-
dice, the rapid enlargement, and the more marked cachexia will usually
suffice to differentiate it. Perhaps the most puzzling conditions occur
in the rare cases of enlarged amyloid liver with irregular gummata. The
large echinococcus liver may present a striking similarity to carcinoma,
but the projecting nodules are usually softer, the disease lasts much longer,
and the cachexia is not marked.
Hypertrophic cirrhosis may at first be mistaken for carcinoma, as the
jaundice is usually deep and the liver very large ; but the absence of a
marked cachexia and wasting, and the painless, smooth character of the
enlargement are points against cancer. When in doubt in these cases,
aspiration may be safely performed, and positive indication may be gained
from the materials so obtained. In large, rapidly growing secondary
cancers the superficial rounded masses may almost fluctuate and these
soft tumor-like projections may contain blood. The form of cancer with
cirrhosis can scarcely be separated from atrophic cirrhosis itself. • Perhaps
FATTY LIVER. 455
the wasting is more extreme and more rapid, but the jaundice and the
ascites are identical. Melano-sarcoma causes great enlargement of the
organ. Tliere are frequently symptoms of involvement of other viscera,
as the lungs, kidneys, or spleen. Secondary tumors may develop on the
skin. A very important symptom, not present in all cases, is melanuria,
the passage of a very dark-colored urine, which may, however, when first
voided, be quite normal in color. The existence of a melano-sarcoma of
the eye, or the history of blindness in one eye, with subsequent extirpa-
tion, may indicate at once the true nature of the hepatic enlargement.
The secondary tumors may develop some time after the extirpation of the
eye, as in a case under the care of J. C. Wilson, at the Philadelphia Hos-
pital, or, as in a case under Tyson at the same institution, the patient
may have a sarcoma of the choroid which had never caused any symp-
toms. Primary cancer of the gall-bladder can rarely be diagnosed. It
may be greatly dilated and readily palpable. Occasionally tumors of the
kidney or a tumor of the transverse colon may be confounded with it.
The treatment must be entirely symptomatic — allaying the pain, re-
lieving the gastric disturbance, and meeting other symptoms as they arise.
VII. FATTY LIVER.
Two different forms of this condition are recognized — the fatty infil-
tration and fatty degeneration.
Fatty infiltration occurs, to a certain extent, in normal livers, since
the cells always contain minute globules of oil.
In fatty degeneration, which is a much less common condition, the
protoplasm of the liver-cells is destroyed and the fat takes its place, as
seen in cases of malignant jaundice and in phosphorus poisoning.
Fatty liver occurs under the following conditions : {a) In association
with general obesity, in which case the liver appears to be one of the
store-houses of the excessive fat. {h) In conditions in which the oxida-
tion processes are interfered with, as in cachexia, profound anaemia, and in
phthisis. The fatty infiltration of the liver in heavy drinkers is to be
attributed to the excessive demand made by the alcohol upon the oxygen.
{c) Certain poisons, of which phosphorus is the most characteristic, pro-
duce an intense fatty degeneration with necrosis of the liver-cells. The
poison of acute yellow atrophy, whatever its nature, acts in the same way.
The fatty liver is uniformly increased in size. The edge may reach
below the level of the navel. It is smooth, looks pale and bloodless ; on
section it is dry, and renders the surface of the knife greasy. The organ
may weigh many pounds, and yet the specific gravity is so low that the
entire organ floats in water.
The symptoms of fatty liver are not definite. Jaundice is never pres-
ent; the stools may be light-colored, but even in the most advanced grades
456 DISEASES OF THE DIGESTIVE SYSTEM.
the bile is still formed. Signs of portal obstruction are rare. Haemor-
rlioids are not very infrequent. Altogether, the symptoms are ill-defined,
and chiefly those of the disease with which the degeneration is associated.
In cases of great obesity, the physical examination is uncertain ; but in
phthisis and cachectic conditions, the organ can be felt, greatly enlarged,
smooth, and painless. Fatty livers are among the largest met with at the
bedside.
VIII. AMYLOID LIVER.
The waxy, lardaceous, or amyloid liver occurs as part of a general
degeneration, associated with cachexias, particularly when the result of
long-standing suppuration.
In practice, it is found oftenest in the prolonged suppuration of tuber-
culous disease, either of the lungs or of the bones. Xext in order of fre-
quency are the cases associated with syphilis. Here there may be ulcera-
tion of the rectum, with which it is often connected, or chronic disease of
the bone, or it may be present when there are no suppurative changes. It
is found occasionally in rickets, in prolonged convalescence from the infec-
tious fevers, and in the cachexia of cancer.
The amyloid organ is large, and may attain dimensions equalled only
by that of the cancerous organ. AYilks speaks of a liver weighing four-
teen pounds. It is solid, firm, resistant, on section anaemic, and has a
semitranslucent, infiltrated appearance. Stained with a dilute solution of
iodine, the areas infiltrated with the amyloid matter assume a rich mahog-
any-brown color. The precise nature of this change is still in question.
It first attacks the capillaries, usually of the median zone of the lobules,
and subsequently the interlobular vessels and the connective tissue. The
cells are but little if at all affected.
There are no characteristic symptoms of this condition. Jaundice
does not occur ; the stools may be light-colored, but the secretion of bile
persists. The physical examination shows the organ to be uniformly en-
larged and painless, the surface smooth, the edges rounded, and the con-
sistence greatly increased. Sometimes the edge, even in very great enlarge-
ment, is sharp and hard. The spleen also may be involved, but there are
no evidences of portal obstruction.
The diagnosis of the condition is, as a rule, easy. Progressive and
great enlargement in connection with suppuration of long standing or
with syphilis, is almost always of this nature. In rare instances, however,
the amyloid liver is reduced in size.
In IPAihrnmia the liver may attain considerable size and be smooth and
uniform, resembling, on physical examination, the fatty organ. The blood
condition at once indicates the true nature of the case.
IliEMORRIIAGE. 457
IX. DISEASES OF THE PAIS^CREAS.
I. HAEMORRHAGE.
Of late years much attention has been paid to this condition, which
may prove rapidly fatal and has important medico-legal bearings. F. W.
Draper * has reported five cases, in all of which death occurred either sud-
denly or after a very short illness. The symptoms are thus briefly sum-
marized by Prince :
" The patient, who has previously been perfectly well, is suddenly taken
with the illness which terminates his life. . . . When the haemorrhage
occurs the patient may be quietly resting or pursuing his usual occupa-
tion. The pain which ushers in the attack is usually very severe, and lo-
cated in the upper part of the abdomen. It steadily increases in severity,
is sharp or perhaps colicky in character. It is almost from the first ac-
companied by nausea and vomiting ; the latter becomes frequent and ob-
stinate, but gives no relief. The patient soon becomes anxious, restless,
and depressed ; he tosses about, and only with difficulty can be restrained
in bed. The surface is cold, and the forehead is covered with a cold sweat.
The pulse is weak, rapid, and sooner or later imperceptible. The abdo-
men becomes tender, the tenderness being located in the upper part of the
abdomen or epigastrium. Tympanites is sometimes marked. The tem-
perature in most cases is either normal or below normal. The bowels are
apt to be constipated. These symptoms continue without relief; those
which are most striking being the pain, vomiting, anxiousness, restless-
ness, and the state of collapse into which the patient soon falls."
Post mortem, the pancreas is found uniformly infiltrated with blood.
Death, as Zenker suggests, is probably due to shock through the solar
plexus.
There are cases in which extensive hasmorrhage occurs into the mesen-
tery, retroperitonaeum, or mesocolon. In a patient of Bruen's, at the
Philadelphia Hospital, who had for some days obscure abdominal symp-
toms, I found the entire mesentery and retroperitonaeum infiltrated with
blood-clots. There was no disease of the aorta or of the coeliac branches
or of the mesenteric vessels. Isambard Owen has reported a case of sud-
den death in a woman aged sixty-seven from haemorrhage into the trans-
verse mesocolon.
* Transactions of the Association of American Physicians, voh i.
30
458 DISEASES OP THE DIGESTIVE SYSTEM.
II. ACUTE PANCREATITIS.
(a) Acute Haemorrhagic Pancreatitis. — The admirable studies of Fitz*
have crystiillized our knowledge on this subject, and brought the affection
within the scope of the diagnostician. A majority of the cases occur in
persons over thirty. Many of the patients had been addicted to alcohol,
and many had suffered from attacks of indigestion, occasionally with severe
pains and vomiting.
Morbid Anatomy. — The pancreas is found enlarged, and the interlobu-
lar tissue infiltrated with blood, and perhaps with clots. In some instances
the contiguous tissues may also be hsemorrhagic, and the whole may form
a large, firm mass, situated at the upper and back part of the abdominal
cavity. The root of the mesentery, the mesocolon, and the omentum
may also show haemorrhages ; the other organs may be practically normal.
In some instances there can be seen about the lobules areas of opaque
white tissue, and upon the omentum and mesentery similar opaque, white
specks, which will be referred to subsequently as the fatty necrosis of
Balser. In spots the gland-cells may also be found necrotic, while there
may be cases showing a marked increase in the fibrous tissue.
The symptoms of this condition are remarkable. The attack sets in
with violent pain in the abdomen, usually in the upper zone, but in some
instances it is general. Nausea and vomiting are present, and usually con-
stipation. Tympanitic distention of the abdomen is of frequent occurrence.
Fever may be present, but is an inconstant symptom. There may be early
delirium. Collapse symptoms supervene, and death occurs usually from the
second to the fourth day, or even earlier. The swelling and infiltration in
the region of the pancreas necessarily involve the coeliac plexus, and the
stretching of the nerves may account for the agonizmg pain and the sud-
den collapse. In a case which I have reported the semilunar ganglia
were swollen, the nerve-cells indistinct, and there was an interstitial infil-
tration of round cells. The Pacinian corpuscles in the neighborhood of
the pancreas were enormously swollen and cedematous.
A diagnosis of intestinal obstruction or of acute perforative peritonitis
is usually made. A correct diagnosis was made in one case by Fitz, and
the possibility of the presence of this condition must be considered in all
abdominal cases which come on suddenly with intense pain in the epi-
gastric region, vomiting, and distention of the abdomen. Perforation of
a peptic ulcer or perforation from gall-stones might produce similar
symptoms, but the previous history would give important indications. In
the case in which the diagnosis was made by Fitz, the patient was sud-
denly seized with severe pain in the epigastrium, followed by vomiting
and prostration. The abdomen was distended, temperature slightly ele-
vated, and the bowels were constipated. The diagnosis lay between ob-
* Middleton-Goldsmitli Lecture. New York Medical Record, vol. i, 1889.
ACUTE PANCRPUTITIS. 459
struction, perforative peritonitis, and acute pancreatitis. Laparotomy was
performed, but no obstruction found. The autopsy showed acute ha3mor-
rhagic pancreatitis.
The cases are stated to be uniformly fatal, but recovery may occur, as
shown by a case which was admitted to the Johns Hopkins Hospital.
Symptoms of obstruction of the bowels had persisted for three or four
days, the abdomen was distended, tender, and very painful. I saw the
patient on admission, concurred in the diagnosis of probable obstruction,
and, as the condition was serious, ordered him to be transferred at once to
the operating-room. The coils were distended and injected, and the peri-
toneal cavity contained a small amount of bloody serum. No obstruction
was found, but in the region of the pancreas and at the root of the mesen-
tery there was a dense, thick, indurated mass and there were areas of fat-
necrosis in both mesentery and omentum. The patient recovered.
The literature of the past few years shows that this affection is much
more frequent than has been supposed. It has a very important clinical
and medico-legal bearing.
A point of interest is the relation of the fat-necrosis to pancreatic
disease. The areas are found in the interlobular pancreatic tissue, in the
mesentery, in the omentum, and in the abdominal fatty tissue generally.
In the pancreas the lobules are seen to be separated by a dead-white
necrotic tissue, which gives a remarkable appearance to the section. In
the abdominal fat the areas are usually not larger than a pin's head ; they
at once attract attention, and may be mistaken, on superficial examina-
tion, for miliary tubercles or neoplasms. They may be larger ; instances
have been reported in which they were the size of a hen's Qgg. On section
they have a soft, tallowy consistence. Langerhans has shown that this
substance is a combination of lime with certain fatty acids. They may be
crusted with lime, and in a man, aged eighty, who died of Bright's disease,
I found the lobules of the pancreas entirely isolated by areas of fatty ne-
crosis with extensive deposition of lime salts. There is no necessary etiolog-
ical relation between disease of the pancreas and disseminated fatty necro-
sis of the abdomen. Cases have been found accidentally in laparotomy for
ovarian tumor and in instances in which the pancreas has been normal.
They may be found in thin persons. The hacterium coli commu7ie was
present in two cases, with diphtheritic colitis, examined by Welch.
(h) Suppurative Pancreatitis. — Of twenty-two cases analyzed by Fitz,
the majority occurred in adults under forty years of age ; seventeen were
males. Anatomically, there may be a diffuse suppuration throughout the
organ, which is studded with small abscesses. In other instances the
abscess cavity is large and the pancreas is converted into an irregular
cyst filled with creamy pus. In more chronic cases the abscess may be
circumscribed and the contents cheesy. Communications sometimes oc-
cur with the duodenum, or the abscess may burst into the peritonaeum.
Although the disease is usually chronic, it begins with epigastric pain,
4:60 DISEASES OP THE DIGESTIVE SYSTEM.
vomiting, and sometimes prostration. There is irregular fever, and death
may occur in three or four weeks. In more chronic cases there is very
slight fever or only occasional paroxysms. The disease may persist for
weeks, months, or even for a year.
The symptoms are indefinite and the condition could scarcely be made
out during life. Tenderness exists in the epigastrium, or may at times
extend to the left and be quite sharply localized over the position of the
pancreas, but a circumscribed tumor is rare. Fat-necrosis is not often
found post mortem in these cases.
(c) Gangrenous Pancreatitis.— Fitz has collected fifteen cases. The
pancreas may be converted into a dark, slate-colored, stinking mass, or it
may lie nearly free in the omental cavity, attached only by a few shreds of
fibrous tissue. Complete sequestration of the organ is not uncommon.
It may be discharged as a slough from the bowels, and in two cases
in Avhich this happened recovery took place. As a rule, acute perito-
nitis follows. Haemorrhagic pancreatitis may precede or be associated
with it. Death occurs with symptoms of collapse, commonly in from ten
to twenty days. Disseminated fat-necrosis is usually present.
III. CHRONIC PANCREATITIS.
The organ is firmer than normal, the interstitial connective tissue is
increased, and there is more or less change in the secreting structures. A
special interest has been aroused lately in this affection, as it has been fre-
quently found in diabetes. There may be marked pigmentary changes ;
a similar condition has been found in the liver. Degeneration of the
glandular elements is present in these cases. The sclerosis may be associ-
ated with calculi in the ducts.
IV. PANCREATIC CYSTS.
These commonly result from the impaction of calculi ; either biliary,
lodging at the orifice of the common duct, or pancreatic, within the duct
of AVirsung. The pancreatic concretions consist usually of carbonate of
lime. W. W. Johnston has collected 35 cases from the literature. Ob-
literation of the duct may also result from cicatricial contraction and
occasionally from displacement. Eighteen cases of cysts of the pancreas
have been collected by Senn. The chief symptoms are tumor in the epi-
gastric region, usually median, or sometimes to one side. AVhen large it
has occupied the whole abdominal cavity, and in such instances the diag-
nosis of ovarian tumor has usually been made. The tumor may develop
rapidly, or may be chronic and last for many years. In some instances
the tumor attained a large size within a few weeks. Pain is not neces-
CANCER. 4G1
sarily present. Fatty diarrhoea did not exist in any of the cases. The
stools may be clay-colored, copious, and putrescent.
The diagnosis of the condition must be extremely difficult, yet it
seems to have been made in 7 of the 18 cases. Aspiration should be made
to determine the nature of the fluid. This has varied considerably, but
most frequently has been brownish or chocolate-colored. In only G of the
17 cases in which the nature is mentioned was the fluid of a clear serous
character.
V. CANCER.
This is usually scirrhus, and may be primary or secondary. It is not
common, as may be judged by the analysis by Segre, who found in 11,492
autopsies only 132 tumors of the pancreas, 127 of which were carcinomata,
2 sarcomata, 2 cysts, and 1 syphiloma. In only 12 of the cases of carcino-
ma was the disease limited to the gland. The head is commonly affected,
and the disease may be limited to this part or extend to it from the stom-
ach or intestines.
The symptoms are variable, and a diagnosis is not often possible.
There may be stearrhoea, though it is to be remembered that fatty diar-
rhoea is not invariably associated with disease of the pancreas, day-col-
ored, greasy, and loose stools may be present, with undigested food, as
noted by T. J. Walker as a symptom of obstruction of the pancreatic
duct. Diabetes may coexist. Although the head of the pancreas can be
felt in very thin persons, the tumor masses can rarely be palpated. In
the analysis of 137 cases by Da Costa, in only 13 was the tumor recognized
by palpation. The general symptoms are those of internal carcinoma.
Progressive emaciation, loss of strength, and dyspepsia are present. There
is pain in the epigastrium, sometimes paroxysmal. When the head of the
pancreas is involved jaundice is almost invariably present.
The disease can scarcely ever be distinguished from cancer in the
pyloric zone with involvement of the glands in the hilus of the liver. The
movable character of the pyloric tumor and the absence of the hydro-
chloric acid in the vomit are valuable points. Tumor of the transverse
colon is more superficial and movable, is often associated with temporary
obstruction, and there may be haemorrhage from the bowels. In a case
with progressive emaciation, epigastric pain, and deep-seated, immobile
tumor, with the presence of fatty and greasy stools and the gradual devel-
opment of jaundice, the diagnosis of cancer of the pancreas is probable.
As the wasting proceeds the aortic pulsation is transmitted with great
force through the pancreas and transverse colon, and when a tumor is
present the diagnosis of aneurism may be made ; but in the latter the
sac has not an up-and-down jerking pulsation, but is distensile. In doubt-
ful tumors in this region the examination should also be made in the knee-
elbow position.
462 DISEASES OF THE DIGESTIVE SYSTEM.
Of other new growths in the pancreas, tubercle may be mentioned as
a rare occurrence ; a few cases of syphiloma have been described.
The treatment of new growths in the pancreas is entirely symptomatic.
X. DISEASES OF THE PERITONEUM.
I. ACUTE GENERAL PERITONITIS.
Definition. — Acute inflammation of the peritonaeum.
Etiology. — The condition may be primary or secondary.
(a) Primary, Idiopathic Peritonitis. — Considering how frequently the
pleura and pericardium are primarily inflamed the rarity of idiopathic
inflammation of the peritonaeum is somewhat remarkable. It may follow
cold or exposure and is then known as rheumatic peritonitis. Xo instance
of the kind has come under my notice. Occasionally in Bright's disease
acute peritonitis develops as a terminal event.
(b) Secondary Peritonitis is due to extension of inflammation from, or
perforation of one of the organs covered by the peritonaeum. Peritonitis
from extension may follow inflammation of the stomach or intestines,
extensive ulceration in these parts, cancer, acute suppurative inflammations
of the spleen, liver, pancreas, retroperitoneal tissues, and the pelvic viscera.
Perforative peritonitis is the most common, following external wounds,
perforation of ulcer of the stomach or bowels, perforation of the gall-
bladder, abscess of the liver, spleen, or kidneys. Two important causes
arc appendicitis and suppurating inflammation about the Fallopian tubes
and ovaries. There are instances in which peritonitis has followed rujoture
of an apparently normal Graafian follicle.
The peritonitis of septicaemia and pyaemia is almost invariably the re-
sult of a local process. An exceedingly acute form of peritonitis may be
caused by the development of tubercles on the membrane.
Morbid Anatomy. — In recent cases, on opening the abdomen the
intestinal coils are distended and glued together by lymph, and the peri-
tonaeum presents a patchy, sometimes a uniform injection. The exuda-
tion may be : {a) Fibrinous, with little or no fluid, except a few pockets
of clear serum between the coils, (b) Sero-fibrinous. The coils are cov-
ered with lymph, and there is in addition a large amount of a yellowish,
8ero-fil)rinous fluid. In instances in which the stomach or intestine is
perforated tliis may be mixed with food or faeces, (c) Purulent, in which
the exudate is either thin and greenish yellow in color, or opaque white
and creamy, (d) Putrid. Occasionally in puerperal and perforative peri-
tonitis, particularly when the latter has been caused by cancer, the exudate
is thin, grayish green in color, and has a gangrenous odor, (c) IIa3mor-
rhagic. This is sometimes found as an admixture in cases of acute peri-
ACUTE GENERAL PERITONITIS. 463
toDitis following wounds, and occurs in the cancerous and tuberculous
forms.
The amount of the effusion varies from half a litre to twenty or thirty
litres. There are probably essential differences between the various kinds
of peritonitis, and bacteriology is beginning to give us valuable informa-
tion on this point. Of the species of micro-organisms which have been
found in peritoneal exudates, the pyogenic micrococci and the bacterium
coli comnume are the most common, sometimes one species, often several
species being found in the same case. The streptococcus pyogenes is by
far the most frequent cause of puerperal peritonitis. This species, and
still oftener the staphylococcus pyogenes aureus^ or albus^ are found in
peritonitis consecutive to laparotomy. The bacterium coli commune^ usu-
ally combined with other bacteria, is met with especially in peritonitis
secondary to intestinal perforation. The diplococcus ptneumonice has been
found several times in peritoneal exudates. The amoeba coli occurred in
numbers in the thin fibrinous effusion in one of our cases of amoebic
dysentery.
Symptoms. — In the perforative and septic cases the onset is marked
by chilly feelings or an actual rigor with intense pain in the abdomen. In
typhoid fever, when the sensorium is benumbed, the onset may not be
noticed. The pain is general and is usually intense and aggravated by
movements and pressure. A position is taken which relieves the tension
of the abdominal muscles, so that the patient lies on the back with the
thighs drawn up and the shoulders elevated. The greatest pain is usually
below the umbilicus, but in peritonitis from perforation of the stomach
pain may be referred to the back, the chest, or the shoulder. The respira-
tion is superficial — costal in t3^pe — as it is painful to use the diaphragm.
For the same reason the action of coughing is restrained, and even the
movements necessary for talking are limited. In this early stage the sensi-
tiveness may be great and the abdominal muscles are often rigidly con-
tracted. If the patient is at perfect rest the pain may be very slight, and
there are instances in which it is not at all marked, and may, indeed, be
absent.
The abdomen gradually becomes distended and tense and is tympanitic
on percussion. The pulse is rapid, small, and hard, and often has a peculiar
wiry quality. It ranges from 110 to 150. The temperature may rise rap-
idly after the chill and reach 104° or 105°, but the subsequent elevation is
moderate. The tongue at first is white and moist, but subsequently be-
comes dry and often red and fissured. Vomiting is an early and promi-
nent feature and causes great pain. The contents of the stomach are first
ejected, then yellowish and bile-stainod fluid, and finally a greenish and,
in rare instances, a brownish-black liquid with sliglit faecal odor. The
bowels may be loose at the onset and then constipation follows. Frequent
micturition may be present, less often retention. 'J'hc urine is usually
scanty and high-colored, and contains a large quantity of indican.
464: DISEASES OF THE DIGESTIVE SYSTEM.
The appearance of the patient when these symptoms have fully devel-
oped is very characteristic. The face is pinched, the eyes are sunken, and
the expression is very anxious. The constant vomiting of fluids causes a
wasted appearance, and the hands sometimes present the washer-woman's
skin. Except in cholera, we see the Ilippocratic facies more frequently
in ,this than in any other disease — " a sharp 7iose, hollow eyes, collapsed
temples ; the ears cold, contracted, and their lobes turned out; the skin
about the forehead being rough, distended, and parched ; the color of the
whole face being broivn, black, livid, or lead-colored.'''' There are one or
two additional points about the abdomen. The tympany is usually ex-
cessive, owing to the great relaxation of the walls of the intestines by in-
flammation and exudation. The splenic dulness may be obliterated, the
diaphragm pushed up, and the apex beat of the heart dislocated to the
fourth interspace. The liver dulness may be greatly reduced, or may, in
the mammary line, be obliterated. It has been claimed that this is a dis-
tinctive feature of perforative peritonitis, but on several occasions I have
been able to demonstrate that the liver dulness in the middle and mam-
mary line was obliterated by tympanites alone. In the axillary line, on
the other hand, the liver dulness, though diminished, may persist. Pneumo-
peritonseum following perforation more certainly obliterates the hepatic
dulness. In such cases the fluid effused produces a dulness in the lateral
region ; but with gas in the peritonaeum, if the patient is turned on the
left side, a clear note is heard beneath the seventh and eighth ribs in the
axillary line.
Effusion of fluid — ascites — is usually present except in some acute,
rapidly fatal cases. The flanks are dull on percussion. The dulness may
be movable, though this depends altogether upon the degree of adhesions.
There may be considerable effusion without either movable dulness or
fluctuation. A friction-rub may be present, as first pointed out by Bright,
but it is not nearly so common in acute as in certain forms of chronic
peritonitis.
Course. — The acute diffuse peritonitis usually terminates in death.
The most intense forms may kill within thirty-six or forty-eight hours ;
more commonly death results in four or five days, or the attack may be
prolonged to eiglit or ten days. The pulse becomes more rapid, all the
symptoms are aggravated, the vomiting persists and the patient usually
dies in collapse with a falling temperature. Occasionally death occurs
with great suddenness, owing, possibly, to paralysis of the heart.
Diagnosis. — In typical cases the severe pain at onset, the distention
of the alxlonuMi, the tenderness, the fever, the gradual development of
effusion, collapse symptoms, and the vomiting give a characteristic picture.
Careful inquiries should at once be made concerning the previous condi-
tion, from which a clew can often be had as to the starting-point of the
trouble. In young adults a considerable proportion of all cases depends
upon perforating appendicitis, and there may be an account of previous
ACUTE GENERAIi PERlTONITrS. 465
attacks of pain in the iliac region, or of constipation alternating with diar-
rha3a. In women the most frequent causes are suppurative processes in
the pelvic viscera, either associated with salpingitis, abscesses in the broad
ligaments, or acute puerperal infection. Perforation of gastric ulcer is
more common also in women. It is not always easy to determine the
cause. Many cases come under observation for the first time with the
abdomen distended and tender, and it is impossible to make a satisfactory
examination. In such instances the pelvic organs should be examined
with the greatest care. In typhoid fever, if the patient is conscious, the
sudden onset of pain, the development of great meteorism, and the aggra-
vation of the general symptoms indicate clearly what has happened.
When the patient is in deep coma, on the other hand, the perforation may
be overlooked. The following conditions are most apt to be mistaken for
acute peritonitis :
{a) Acute Enter o-colitis. — Here the pain and distention and the sen-
sitiveness on pressure may be marked. The pain is more colicky in char-
acter, the diarrhoea is more frequent, and the collapse is more extreme.
{h) The So-called Hysterical Peritonitis. — This has deceived the very
elect, as almost every feature of genuine peritonitis, even the collapse, may
be simulated. The onset may be sudden, with severe pain in the abdomen,
tenderness, vomiting, diarrhoea, difficulty in micturition, and the charac-
teristic decubitus. Even the temperature may be elevated. There may be
recurrence of the attack. A case has been reported by Bristowe in which
four attacks occurred within a year, and it was not until special hysterical
symptoms developed that the true nature of the trouble was suspected.
(c) Obstruction of the hoioel^ as already mentioned, may simulate peri-
tonitis, both having pain, vomiting, tympanites, and constipation in com-
mon. It may for a couple of days really be impossible to make a diagnosis
in the absence of a satisfactory history.
{d) Rupture of an aMominal aneurism or embolism of the superior
mesenteric artery may cause symptoms which simulate peritonitis. In the
latter, sudden onset with severe pain, the collapse symptoms, frequent
vomiting, and great distention of the abdomen may be present.
(e) I have already referred to the fact that acute haemorrhagic pan-
creatitis may be mistaken for peritonitis. Lastly, a ruptured tubal preg-
nancy may resemble acute peritonitis. A patient was admitted to my
wards in an enfeebled condition, with a thready pulse, distended and ten-
der abdomen, and signs of fluid. The attack had come on suddenly four
days before, when she had been in perfect health. She looked pale, the
blood count was taken and found below three millions per cubic centi-
metre, with leucocytosis, a condition rather indicating anaemia from hasm-
orrhage. The abdomen was tapped with a fine aspirator needle and a
bloody fluid withdrawn. The diagnosis of probable ruptured tubal preg-
nancy was made and the patient was transferred to the gynaecological de-
partment, where laparotomy was performed and the ruptured tube removed.
466 DISEASES OF THE DIGESTIVE SYSTEM.
11. PERITONITIS IN INFANTS.
Peritonitis may occur in the foetus as a consequence of syphilis, and
may lead to constriction of the bowel by fibrous adhesions.
In the new-born a septic peritonitis may extend from an inflamed cord.
Distention of the abdomen, slight swelling and redness about the cord, and
not infrequently jaundice are present. It is an uncommon event, and
existed in only four of fifty-one infants dying of inflammation of the cord
and septicaemia (Runge).
During childhood peritonitis develops from causes similar to those af-
fecting the adult. Perforative appendicitis is common. Peritonitis fol-
lowing blows or kicks on the abdomen occurs more frequently at this
period. In boys injury while playing foot-ball may be followed by diffuse
peritonitis. A rare cause in children is extension through the diaphragm
from an empyema. There are on record instances of peritonitis occurring
in several children at the same school, and it has been attributed to sewer-
gas poisoning. It was in investigating an epidemic of this kind at the
Wandworth school, in London, that Anstie received the post-mortem
wound of which he died.
III. LOCALIZED PERITONITIS.
The inflammation may be confined to the lesser peritonaeum, particu-
larly in cases of perforation of the stomach. A large air-containing abscess
may form beneath the diaphragm, inducing the condition known as pyo-
pneumothorax subphrenicus. More frequent is the circumscribed perito-
nitis due to inflammation of the appendix. If the vermiform process is
free, adhesions take place which circumscribe the process. The most
common situation is a localized abscess upon the psoas muscle, bounded
by the caecum on the right and the terminal portion of the ileum and its
mesentery in front and on the left. The limitation may be complete, and
post-mortem observation shows that healing follows in a large number of
such cases. In other instances the localized peritonitis is more extensive
and a large abscess cavity is gradually formed in tlie right iliac fossa,
which may still be intraperitoneal, though shut off from the general sac.
A more frequent cause of local peritonitis is inflammation about the uterus
and Fallopian tubes, and here the primary disease is usually puerperal or
gonorrhonal, less frequently tuberculous. The fimbriae become adherent
and closely matted to the ovary, and there is gradually produced a condi-
tion of thickening and matting of the parts in which the individual organs
are scarcely recognizable. An acute process extending from this may in-
volve only the pelvic membranes, being shut off from the general peri-
tonaeum by adhesions of the coils of the intestines.
CriKONIC PEllITONITrS. 407
IV. CHRONIC PERITONITIS.
The following varieties may be recognized : (a) Local adhesive perito-
nitis, a very common condition, which occurs particularly about the spleen,
forming adhesions between the capsule and the diaphragm, about the liver,
less frequently about the intestines and mesentery. Points of thickening
or puckering on the peritonaeum occur sometimes with union of the coils
or fibrous bands. In a majority of such cases the condition is met acci-
dentally post mortem. Two sets of symptoms may, however, be caused
by these adhesions. When a fibrous band is attached in such a way as
to form a loop or snare, a coil of intestine may pass through it. Thus,
of the 295 cases of intestinal obstruction analyzed by Fitz, 63 were due to
this cause. The second group is less serious and comprises cases with
persistent abdominal pain of a colicky character, sometimes rendering life
miserable. Instances of this kind have been successfully operated upon
by Homans and H. A. Kelly.
(b) Diffuse Adhesive Peritonitis. — This is a consequence of an acute
inflammation, either simple or tuberculous. The peritonaeum is obliter-
ated. On cutting through the abdominal wall, the coils of intestines are
uniformly matted together and can neither be separated from each other
nor can the visceral and parietal layers be distinguished. There may be
thickening of the layers, and the liver and spleen are usually involved in
the adhesions.
(c) Proliferative Peritonitis. — Apart from cancer and tubercle, which
produce typical lesions of chronic peritonitis, the most characteristic
form is that which may be described under this heading. The essential
anatomical feature is great thickening of the peritoneal layers, usually
without much adhesion. The cases are sometimes found with cirrhosis of
the stomach. In one instance I found it in connection with a cirrhotic
condition of the caecum and the first part of the colon. In the inspection
of a case of this kind there is usually moderate effusion, more rarely exten-
sive ascites. The peritonaeum is opaque-white in color, and everywhere
thickened, often in patches. The omentum is usually rolled and forms a
thickened mass transversely placed between the stomach and the colon.
The peritonaeum over the stomach, intestines, and mesentery is sometimes
greatly thickened. The liver and spleen may simply be adherent, or there
is a condition of chronic perihepatitis or perisplenitis, so that a layer of
firm, almost gristly connective tissue of from one fourth to half an inch
in thickness encircles these organs. Usually the volume of the liver is in
consequence greatly reduced. The gastro-hepatic omentum may be con-
stricted by this new growth and the calibre of the portal vein much nar-
rowed. A serous effusion may be present. On account of the adhesions
which form, the peritonaeum may be divided into three or four different
sacs, as is more fully described under the tuberculous peritonitis. In these
cases the intestines are usually free, thougli the mesentery is greatly
468 DISEASES OP THE DIGESTIVE SYSTEM.
shortened. There are instances of chronic peritonitis in which the mes-
entery is so shortened by this proliferative change that the intestines form
a ball not larger than a cocoa-nut situated in the middle line, and after re-
moval of the exudation can be felt as a solid tumor. The intestinal wall
is greatly thickened and the mucous membrane of the ileum is thrown
into folds like the valvulae conniventes. This proliferative peritonitis is
found frequently in the subjects of chronic alcoholism.
In all forms of chronic peritonitis a friction may be felt usually in the
upper zone of the abdomen.
In some instances of chronic peritonitis the membrane presents numer-
ous nodular thickenings, which may be mistaken for tubercles. They
may be scattered in numbers on the membranes, and it may be extremely
difficult, without the most careful microscopical examination, to deter-
mine their nature. J. F. Payne has described a case of this sort associ-
ated with disseminating growths throughout the liver which were not
cancerous. It has been suggested that some of the cases of tuberculous
peritonitis cured by operation have been of this nature, but histological
examination would, as a rule, readily determine between the conditions.
Miura, in Japan, has reported a case in which these nodules contained the
ova of a parasite.
(d) Chronic Haemorrhagic Peritonitis. — Blood-stained effusions in the
peritonaeum occur particularly in cancerous and tuberculous disease. There
is a form of chronic inflammation analogous to the haemorrhagic pachymen-
ingitis of the brain. It was described first by Virchow, and is localized
most commonly in the pelvis. Layers of new connective tissue form on
the surface of the peritonaeum with large wide vessels from which haemor-
rhage occurs. This is repeated from time to time with the formation of
regular layers of haemorrhagic effusion. It is rarely diffuse, more com-
monly circumscribed.
V. NEW GROWTHS IN THE PERITONvCUM.
(a) Tuberculous Peritonitis. — This has already been considered.
(b) Cancer of the Peritonseum. — Although as a rule secondary to dis-
ease of the stomach, liver, or pelvic organs, cases of primary cancer are
occasionally found. Secondary malignant peritonitis occurs in connection
with all forms of cancer. It is usually characterized by a number of
round tumors scattered over the entire peritonaeum, sometimes small and
miliary, at others large and nodular, with puckered centres. The disease
most commonly starts from the stomach or tlie ovaries. The omentum is
indurated, and, as in tuberculous peritonitis, forms a mass which lies
transversely across the upper portion of the abdomen. Primary malig-
nant disease of the peritonaeum is extremely rare. Colloid has occurred,
forming enormous masses, which in one case weighed over one hundred
ASCITES. 409
pounds. Cancer of this membrane spreads, either by the detachment of
small particles which are carried in the lymph currents and by the move-
ments to distant parts, or by contact of opposing surfaces. It occurs more
frequently in women than in men, and more commonly at the later period
of life.
The diagnosis of cancer of the peritonaeum is easy with a history
of a local malignant disease ; as when it occurs with ovarian tumor or
with cancer of the pylorus. In cases in which there is no evidence of
a primary lesion the diagnosis may be doubtful. The clinical picture is
usually that of chronic ascites with progressive emaciation. There may
be no fever. If there is much effusion nothing definite can be felt on ex-
amination. After tapping, irregular nodules or the curled omentum may
be felt lying transversely across the upper portion of the abdomen. Un-
fortunately, this tumor upon which so much stress is laid occurs as fre-
quently in tuberculous peritonitis and may be present in a typical manner
in chronic proliferative form, so that in itself it has no special diagnostic
value. Multiple nodules, if large, indicate cancer, particularly in persons
above middle life. Nodular tuberculous peritonitis is most frequent in
children. The presence about the navel of secondary nodules and indu-
rated masses is more common in cancer. Inflammation, suppuration, and
the discharge of pus from the navel rarely occur except in tuberculous
disease. Considerable enlargement of the inguinal glands may be present
in cancer. The nature of the fluid in cancer and in tubercle may be much
alike. It may be haemorrhagic in both ; more often in the latter. The
histological examination in cancer may show large multinuclear cells or
groups of cells — the sprouting cell-groups of Foulis — which are extremely
suggestive. The colloid cancer may produce a totally different picture ;
instead of ascitic fluid, the abdomen is occupied by the semi-solid gelati-
nous substance, and is firm, not fluctuating.
And, lastly, there are instances of echinococci in the peritonaeum which
may simulate cancer very closely. I have reported a case of this kind, in
which the enlarged liver and the innumerable nodular masses in the peri-
tonaeum naturally led to this diagnosis.
VI. ASCITES {Ilydro-peritonmum).
Definition. — The accumulation of serous fluid in the peritoneal
cavity.
Etiology. — (1) Local Causes. — {a) Chronic inflammation of the peri-
tonaeum, eitlier simple, cancerous, or tuberculous, [h) Portal obstruction
in the terminal branches within the liver, as in cirrhosis, or by compression
of the vein in the gastro-hepatic omentum, either by proliferative perito-
nitis, by new growths, or by aneurism, (c) Tumors of the abdomen. The
solid growths of the ovaries may cause considerable ascites, which may
470 DISEASES OP THE DIGESTIVE SYSTEM.
completely mask the* true condition. The enlarged spleen in leukaemia,
less commonly in malaria, may be associated with recurring ascites.
(2) General Causes. — The ascites is part of a general dropsy, the re-
sult of mechanical effects, as in heart-disease, chronic emphysema, and
cirrhosis of the lung. In cardiac lesions the effusion is sometimes con-
fined to the peritonaeum, in which case it is due to secondary changes in
the liver, or it has been suggested to be connected with a failure of the
suction action of this organ, by which the peritonaeum is kept dry. Ascites
occurs also in the dropsy of Bright's disease, and in hydraemic states of
the blood.
Symptoms. — A gradual uniform enlargement of the abdomen is the
characteristic symptom of ascites. The physical signs are usually distinct-
ive, (a) Lispection. — According to the amount of fluid the abdomen is
protuberant and flattened at the sides. AVith large effusions, the skin is
tense and may present the lineae albicantes. Frequently the navel itself
and the parts about it are very prominent. In many cases the superficial
veins are enlarged and a plexus joining the mammary vessels can be seen.
Sometimes it can be determined by pressure on these veins that the cur-
rent is from below upward. In some instances, as in thrombosis or oblit-
eration of the portal vein, these superficial abdominal vessels may be ex-
tensively varicose. About the navel in cases of cirrhosis there is occa-
sionally a large bunch of distended veins, the so-called caput Medusae.
(h) Faljmtion. — Fluctuation is obtained by placing the fingers of one
hand upon one side of the abdomen and by giving a sharp tap on the op-
posite side with the other hand, when a wave is felt to strike as a definite
shock against the applied fingers. Even comparatively small quantities of
fluid may give this fluctuation shock. When the abdominal walls are
thick or very fat, an assistant may place the edge of the hand or a piece
of card-board in the front of the abdomen. A different procedure is
adopted in palpating for the solid organs in case of ascites. Instead of plac-
ing the hand flat upon the abdomen, as in the ordinary method, the pads
of the fingers only are placed lightly upon the skin, and then by a sudden
depression of the fingers the fluid is displaced and the solid organ or
tumor may be felt. By this method of " dipping " or displacement, as it
is called, the liver may be felt below the costal margin, or the spleen, or
sometimes solid tumors of the omentum or intestine.
{c) Percussion. — In the dorsal position with a moderate quantity of
fluid in the peritonaeum the flanks are dull, while the umbilical and epi-
gastric regions, into which the intestines float, are tympanitic. This area
of clear resonance may have an oval outline. Having obtained the lateral
limit of the dulness on one side, if the patient then turns on the opposite
side, the fluid gravitates to the dependent part and the uppermost flank is
now tympanitic. In moderate effusions this movable dulness changes
greatly in the different postures. Small amounts of fluid, probably under
a litre, would scarcely give movable dulness, as the pelvis and the renal
ASCITHIS. 471
regions liold a considerable quantity. In such cases it is best to place the
patient in the knee-elbow position, when a dull note will be determined at
the most dependent portion. By careful attention to these details mis-
takes are usually avoided.
The following are among the conditions which may be mistaken for
dropsy : Ovarna?! tumor, in which the sac develops, as a rule, unilaterally,
though when large it is centrally placed. The dulness is anterior and the
resonance is in the flanks, into which the intestines are pushed by the cyst.
Examination ;jer vaginam may give important indications. In those rare
instances in Avhich gas develops in the cyst the diagnosis may be very diffi-
cult. Succussion has been obtained in such cases. A distended Madder
may reach above the umbilicus. In such instances some urine dribbles
away, and suspicion of ascites or a cyst is occasionally entertained. I once
saw a trochar thrust into a distended bladder, which was supposed to be
an ovarian cyst, and it is stated that John Hunter tapped a bladder, sup-
posing it to be ascites. Such a mistake should be avoided by careful
catheterization prior to any operative procedures. And lastly, there are
large pancreatic or hydatid cysts in the abdomen which may simulate
ascites.
Nature of the Ascitic Fluid. — Usually this is a clear serum, light yel-
low in the ascites of anaemia and Bright's disease, often darker in color in
cirrhosis of the liver. The specific gravity is low, seldom more than 1*010
or 1*015. In the fluid of ovarian cysts the specific gravity is high, 1*020 or
over. It is albuminous and sometimes coagulates spontaneously. Hsemor-
rhagic effusion usually occurs in cancer and tuberculosis, and occasionally
in cirrhosis. I have already referred to the instances of haemorrhagic effu-
sion in connection with ruptured tubal pregnancy. A chylous, milky ex-
udate is occasionally found. Busey has collected thirty-three cases from
the literature. There are, as Quincke has pointed out, two distinct varie-
ties, a fatty and a chylous, which may be distinguished by the microscope,
as in the former there are distinct fat-globules. These cases have been
sometimes connected with peritoneal or mesenteric cancer. In the true
chylous ascites the fluid is turbid and milky. In some of the cases, as in
Whitla's, a perforation of the thoracic duct has been found. The condL
tion does not necessarily follow obliteration of the thoracic duct. Mild
grades of chylous ascites, which are occasionally found clinically, may be
due to the fact that the patient upon a milk diet has a permanent
lipa^mia, such as is present in young animals and in diabetics, in whom
the liquor sanguinis is always fatty. Under such circumstances an exu-
date may contain enough of the molecular base of the chyle to produce
turbidity of the fluid. Some of the cases have been associated with
filariosis.
Treatment of the Previous Conditions. — (<^) Acute Peri-
tonitis.— iiest is enjoined upon the patient by the severe pain which fol-
lows the slightest movement, and he should be propped in the position
472 DISEASES OF THE DIGESTIVE SYSTEM.
which gives him greatest relief. For the pain morphia should be injected
hypodermically in full doses. In an adult it is better to give a third or
half a grain at once, and subsequently at intervals repeat it in smaller
doses, as are necessary. The action of the drug should be carefully
watched and the patient should not be allowed to pass into such a degree
of unconsciousness that he cannot be aroused. The respiration and the
condition of the pupils also give valuable information. The amount of
opium which has been given in certain instances is remarkable, and indi-
cates a tolerance of the drug. The doses given by the late Alonzo Clark,
of New York, may be truly termed heroic. Austin Flint notes that a
patient under the care of this physician took " in the first twenty-four
hours, of opium and the sulphate of morphia, a quantity equivalent to 106
grains of opium ; in the second twenty-four hours she took 472 grains ;
on the third day, 23G grains ; on the fourth day, 120 grains ; on the fifth
day, 54 grains ; on the sixth day, 22 grains ; on the seventh day, 18 grains ;
after which the treatment was suspended." It is unnecessary to use these
enormous doses, as, even when the pain is most intense, from a third to
a half grain of morphia every few hours will usually keep the patient
thoroughly under the influence of the drug. In a robust, strong patient,
seen at the outset, twenty leeches applied over the abdomen will give great
relief.
Local applications — either hot turpentine stupes or cloths wrung out
of ice-water — may be laid upon the abdomen. The patients sometimes
declare that they are greatly relieved by the latter.
The question of the use of purgatives in peritonitis has of late been
warmly discussed. Lawson Tait and other gynaecologists have used the
saline purges with the greatest benefit in post-operation peritonitis. Theo-
retically it appears correct to give salines in concentrated form, which
cause a rapid and profuse exosmosis of serum from the intestinal vessels,
relieving the congestion and reducing the oedema, which is one important
factor in causing the meteorism. It is also urged that the increased peri-
stalsis prevents the formation of adhesions. In reading the reports of these
successful cases, one is not always convinced, however, that peritonitis
actually existed. Still, in cases of acute peritonitis due to extension or
following operation or in septic conditions the judgment of many careful
men is decidedly in favor of the use of salines. I cannot speak from per-
sonal experience on this question. The majority of cases of peritonitis
which come under the care of the physician follow lesions of the abdominal
viscera or are due to perforation of ulcer of the stomach, the ileum, or the
appendix. In such cases, particularly in the large group of appendix cases,
to give saline purgatives is, to say the least, most injudicious treatment.
The safety of the patient lies in the restriction of the peristalsis and the
localization of the inflammation, for which purpose opium alone is of
service. In these instances rectal injections should be employed to relieve
the large bowel. No symptom in acute peritonitis is more serious than
ASCITES. 473
the tympanites, and none is more difficult to meet. The use of the long
tube and injections containing turpentine may be tried. Drugs by the
mouth cannot be retained.
For the vomiting, ice and small quantities of soda water may be em-
ployed. The patient should be fed on milk, but if the vomiting is dis-
tressing it is best not to attempt to give food by the mouth, but to use
small nutrient enemata. In all cases of peritonitis it is best to have a sur-
geon in consultation early in the disease, as the question of operation may
come up at any moment. I have already mentioned the conditions under
which laparotomy is indicated in perforative appendicitis. The acute
purulent cases, particularly those in which the streptococci occur, usually
die ; but although the results of operative interference in this form have
not as yet been very brilliant, the condition, we must remember, is almost
hopeless, and too often there has been unnecessary delay in calling in sur-
gical aid. In the acute forms of tuberculous peritonitis operation appears
to be more hopeful, but they are not always successful.
(b) Chronic Peritonitis. — For the cases of chronic proliferative peri-
tonitis very little can be done. The treatment is practically that of ascites.
In all these forms, when the distention becomes extreme, tapping is indi-
cated. The treatment of tuberculous peritonitis has fallen largely into
the hands of the surgeons, and the results in many cases are very good.
According to the statistics of Maurange,* of 71 cases, 28 survived the
operation for more than a year. Of 26 additional cases which I have col-
lected,! 14 were dead at the time of the report. Within tAVO years and
three months there were six operations performed at the Johns Hopkins
Hospital in tuberculous peritonitis, with four recoveries.
(c) Ascites. — The treatment depends somewhat on the nature of the
case. In cirrhosis early and repeated tapping may give time for the estab-
lishment of the collateral circulation, and temporary cures have followed
this procedure. Permanent drainage with Southey's tube, incision, and
washing out the peritonaeum have also been practised. In the ascites
of heart and renal disease the cathartics are most satisfactory, particularly
the bitartrate of potash, given alone or with jalap, and the large doses of
salts given an hour before breakfast with as little water as possible. These
sometimes cause rapid disappearance of the effusion, but they are not so
successful in ascites as in pleurisy with effusion. The stronger cathartics
may sometimes be necessary. The ascites forming part of the general
anasarca of Bright's disease will receive consideration under another section.
* Paris Thesis, 1889.
f On Tuberculous Peritonitis, Johns Hopkins Ilospital Reports, 1890.
81
SECTION IV.
DISEASES OF THE EESPIEATOEY SYSTEM.
I. DISEASES OF THE NOSE.
I. ACUTE CORYZA.
Acute catarrhal inflammation of the upper air-passages, popularly
known as a " catarrh " or a " cold," is usually an independent affection,
but may precede the development of another disease.
Etiology. — It prevails most extensively in the changeable weather of
the spring and early winter, and may occur in epidemic form, many cases
developing in a community within a few weeks. These outbreaks are
very like, though less intense than the epidemic influenza, cases of which
may begin with symptoms of ordinary coryza. The disease probably de-
pends upon a micro-organism. Irritating fumes, such as those of iodine or
ammonia, also may cause an acute catarrh of the nose.
Symptoms. — The patient feels indisposed, perhaps chill}, has slight
headache, and sneezes frequently. In severe cases there are pains in the
back and limbs. There is usually slight fever, the temperature rising to
101°. The pulse is quick, the skin is dry, and there are all the features of
a feverish attack. At first the mucous membrane of the nose is swollen,
" stuffed up," and the patient has to breathe through the mouth. A thin,
clear, irritating secretion flows, and makes the edges of the nostrils sore.
The mucous membrane of the tear-ducts is swollen, so that the eyes weep
and the conjunctivae are injected. With the nasal catarrh there is slight
soreness of the throat and stiffness of the neck ; the pharynx looks red
and swollen, and sometimes the act of swallowing is painful. The larynx
also may be involved, and the voice becomes husky or is even lost. If the
inflammation extends to the Eustachian tubes there may be impairment
of the hearing. Owing to the swelling of the nasal mucosa, the sense of
smell and, in part, the sense of taste are lost. In more severe cases there
are bronchial irritation and cough. Occasionally there is an outbreak of
labial or nasal herpes. Usually witliin thirty-six hours the nasal secretion
becomes turbid and more profuse, the swelling of the mucosa subsides, the
patient gradually becomes able to breathe through the nostrils, and within
CHRONIC NASAL CATARRH. 475
four or five days the symptoms disappear, with the exception of the in-
creased discharge from the nose and upper pharynx. There are rarely any
bad effects from a simple coryza. When the attacks are frequently re-
peated, the disease may become chronic.
The diagnosis is always easy, but caution must be exercised lest the
initial catarrh of measles or severe influenza should be mistaken for the
simple coryza.
Treatment. — Many cases are so mild that the patients are able to be
about and to attend to their work. If there are fever and constitutional
disturbance, the patient should be kept in bed and should take a simple
fever mixture, and at night a drink of hot lemonade and a full dose of
Dover's powder. Many persons find great benefit from the Turkish bath.
For local treatment, particularly in the early stage, when the mucous mem-
brane is swollen and there is a distressing sense of tightness and pain over
the frontal sinuses, cocaine is very useful and sometimes gives immediate
relief. The four per cent solution may be injected into the nostrils, or
cotton-wool soaked in the solution may be inserted into them. Later, the
snuff recommended by Ferrier is advantageous, composed, as it is, of
morphia (gr. ij), bismuth (3 iv), acacia powder (3 ij). This may occa-
sionally be blown or snuffed into the nostrils. Coryza is rarely serious in
itself, but renders the subject more susceptible to other affections. The
attacks should therefore never be slighted, and in young children and in
the old especial care should be taken during convalescence.
II. CHRONIC NASAL CATARRH
{Rhinitis simplex ; Rhinitis hypertrophica ; Rhinitis atrophica).
In simple chronic catarrh there is increased irritability of the mucous
membrane, particularly of the erectile tissue on the septum and turbinated
bones. There is a tendency to frequent stoppage of one or both nostrils
and the patient very easily catches cold. The secretion is at first clear
and afterward thick and tenacious. The sense of smell is not specially
disturbed at this stage. With the mirror the mucous membrane looks
congested and swollen and the veins may be distended.
In hypertrophic rhinitis, which is usually a sequel of the former con-
dition, the nasal passages are obstructed, chiefly by enlargement of the
lower turbinated bodies and swelling of the mucous membrane of the sep-
tum. Very often there is hypertrophy of the adenoid tissue in the vault
of the pharynx and of the mucous membrane about the orifices of the
Eustachian tubes. The two conditions frequently go together as ex-
pressed in the designation, chronic naso-pharyngeal catarrh. The symp-
toms of this hypertrophic rhinitis may be local or general.
The most important local symptom is the obstruction of the passage of
air through the nostrils, so that the patients become mouth-breathers.
476 DISEASES OF THE RESPIRATORY SYSTEM.
During the day this may not be very distressing, but at night the mouth
and throat get extremely dry and the sleep is disturbed. The voice be-
comes nasal in quality and in advanced cases, when the Eustachian tubes
are obstructed, there may be deafness. It should ever be borne in mind by
the practitioner that a very large proportion of all cases of deafness origi-
nate in chronic naso-pharyngeal catarrh. The general symptoms in these
cases, particularly in children, are of the greatest importance, and have
been considered more fully under chronic pharyngeal catarrh and mouth-
breathing. Suffice it here to say that there is produced in children a char-
acteristic facies, associated often with mental dulness and changes in the
form of the thorax.
Atrophic rhinitis^ which is also known under the names coryza fetida
and ozaena, may be a sequence of the hypertrophic form. Ozaena is only a
symptom, and is met with in many ulcerative conditions of the nostrils,
particularly as a result of syphilis, foreign bodies, caries and necrosis of
the bones, and glanders. Fortunately, the atrophic form by no means
necessarily follows the hypertrophic stage. The cases are much more fre-
quent in women than in men, and usually occur early in life. The mucous
membrane is thin and covered with grayish crusts which, when removed,
show a slightly excoriated surface, but true ulcers are rarely seen. The
erectile tissue is completely atrophied by a process of slow connective-tissue
growth, or, as J. N. Mackenzie calls it, a cirrhosis. The mucous mem-
brane of the pharynx is usually dry and glazed.
The symptoms are most distinctive, owing to the horrible odor which
comes from the nose, and of which, fortunately, the patient is himself
unconscious, because the sense of smell is lost. The secretion, which is
puriform, dries and forms large crusts, which are dislodged by picking or
which gradually fall off. The cause of the offensive odor has been much
discussed — whether it is due to a special organism or to specially favorable
conditions for the growth and development of the germs of putrefaction.
Probably the latter view is correct.
The treatment of h3rpertrophic rhinitis consists in the thorough cleans-
ing of the nasal passages, the removal of the pharyngeal growths, and the
reduction of the hypertrophied nasal mucosa. Operative procedures are
necessary in a majority of the cases, and the practitioner should early call
to his assistance the specialist. It is sad to think of the misery which has
been entailed upon thousands of people owing to neglect of naso-pharyngeal
catarrh by parents and physicians.
The treatment of atrophic rhinitis comes more properly under the
special monographs.
AUTUMNAL CATARRH. 477
III. AUTUMNAL CATARRH {Hay Fever).
An affection of the upper air-passages, often associated with asthmatic
attacks, due to the action of certain stimuli upon a hypersensitive mucous
membrane.
This affection was first described in 1819 by Bostock, who called it
catarrlius cBstivus. Morrill AVyman, of Cambridge, Mass., wrote a mono-
graph on the subject, and described two forms, the " June cold," or " rose
cold," which comes on in the spring, and the autumnal form which, in
this country, does not develop until August and September, and never
persists after a severe frost. Blakley studied its connection with the pol-
len of various grasses and flowers. The late George M. Beard made
many careful observations on the disease. Until recently this form of ca-
tarrh was believed to result exclusively from the action of certain irritants
on the mucous membrane of the nose, particularly the pollen of plants,
which, as the experiments of Blakley showed, play an im]3ortant role in
the disease. Other emanations also may induce an attack, as in the case
of the late Austin Flint, who was liable to coryza, or even asthma, if he
slept on a certain sort of feather pillow. This, however, is only one factor
in the disease. A second, most important one, was discovered in the con-
dition of the nasal mucous membrane in these cases. Yoltolini, of Breslau,
in 1871, observed the cure of a case of asthma by the removal of a nasal poly-
pus. Since that date the observations of Hack, in Germany, and particu-
larly of Daly, of Pittsburg ; Roe, of Rochester ; John !N". Mackenzie, of
Baltimore ; and Harrison Allen, of Philadelphia, have demonstrated the
association of asthmatic attacks with nasal disease. Daly discovered that
in a large proportion of the cases of hay asthma there was local disease of
the mucous membrane of the nose, the cure of which rendered the pa-
tient insusceptible to conditions previously exciting the attacks. This has
been abundantly confirmed. Still identical lesions exist in many people
who never suffer with the disease, so that there must be a third factor, a
neurotic constitution. In the etiology of hay fever, then, these three ele-
ments prevail — a nervous constitution, an irritable nasal mucosa, and the
stimulus.
The disease affects certain families, particularly, it is said, those with a
neurotic taint. The peculiarity may occur through several generations.
It is certainly more common in the United States than in Europe, and
much more common in the United States than in Canada. The United
States Hay Fever Association now numbers thousands of members.
Dwellers in cities are more subject than residents in the country. The
structural peculiarities of the nasal mucous membrane are those of hyper-
trophic rhinitis. Harrison Allen states that the inferior turbinated bones
lie well above the floor of the nostrils, which renders the mucous mem-
brane more liable to irritation from inhaled substances. Deflection of the
septum, hypertrophy of the soft parts, and excessive hyperaesthesia, so that
478 DISEASES OF THE RESPIRATORY SYSTEM.
tlie mere touch with a probe may be sufficient to induce an attack, are
common conditions.
Symptoms. — These are, in a majority of the cases, very like those of
* ordinary coryza. There may, however, be much more headache and dis-
tress, and some patients become very low-spirited. Cough is a common
symptom and may be very distressing. Paroxysms of asthma may develop,
so like as to be indistinguishable from the ordinary bronchial form. The
two conditions may indeed alternate, the patient having at one time an
attack of common hay fever and at another, under similar circumstances,
an attack of bronchial asthma. Of the immediate exciting causes of the
attack, unquestionably in a majority of the cases coming on in the autumn
there is an association with the presence of pollen in the atmosphere, but
this is only one of a host of exciting causes. In certain persons the par-
oxysms may develop at any season from sudden changes in the tempera-
ture. An attack may even come on through association of ideas. The
well-known experiment of J. N. Mackenzie, of inducing an attack in a
susceptible person by offering her an artificial rose to smell, strikingly
illustrates the neurotic element in the disease.
Treatm.ent. — This may be comprised under three heads : First, since
the disease appears in many instances to be a form of chronic neurosis,
remedies which improve the stability of the nervous system may be em-
ployed— such as arsenic, phosphorus, and strychnia. Second, climatic.
Dwellers in the cities of the Atlantic sea-board and of the Central States
enjoy complete immunity in the Adirondacks and White Mountains. As
a rule the disease is aggravated by residence in agricultural districts. The
dry mountain air is unquestionably the best ; there are cases, however, which
do well at the seaside. Third, the thorough local treatment of the nose,
particularly the destruction of the vessels and sinuses over the sensitive
areas.
IV. EPISTAXIS.
Etiology. — Bleeding from the nose may result from local or consti-
tutional conditions. Among local causes may be mentioned traumatism,
picking or scratching the nose, new growths, and the presence of foreign
bodies. In chronic nasal catarrh bleeding is not infrequent. The blood
may come from one or both nostrils. The flow may be profuse after an
injury, but is soon checked and is very rarely fatal. Occasionally profuse
and fatal haemorrhage occurs as a result of injury to the skull. In a re-
marka])le case of this kind, coming on some weeks after the receipt of the
injury, I found tluit there had been a fracture across the sphenoid bone
and an erosion hjid taken place into the carotid artery, just where it runs
closest to the sphenoidal sinuses. The young man had completely recov-
ered from the effects of the injury, and the fatal haemorrhage took place as
he was stooping over to wash his face.
EPISTAXIS. 479
Among general conditions with whicli nose-bleeding is associated, the
following are the most important : It occurs with great frequency in grow-
ing children, particularly about the age of puberty ; more frequently in
the delicate than in the strong and vigorous.
Epistaxis is a very common event in persons of so-called plethoric
habits. It is stated sometimes to precede, or to indicate a liability to,
apoplexy, but this is very doubtful.
In venous engorgement, due to heart or pulmonary disease, epistaxis is
not com.mon and there may be a most extreme grade of cyanosis without
its occurrence. In balloon and mountain ascensions, in the very rarefied
atmosphere, haemorrhage from the nose is a common event. In haemo-
philia the nose ranks first of the mucous membranes from which bleeding
arises. It occurs in all forms of chronic anaemias. It precedes the onset
of certain fevers, more particularly typhoid, with which it seems associated
in a special manner. Vicarious epistaxis has been described in cases of
suppression of the menses. Lastly, it is said to be brought on by certain
psychical impressions, but the observations on this point are not trust-
worthy. The blood in epistaxis results from capillary oozing or diapedesis.
The mucous membrane is deeply congested and there may be small ecchy-
moses. The bleeding area is usually in the respiratory portion of one nos-
tril and upon the cartilaginous septum.
Symptoms. — Slight haemorrhage is not associated with any special
features. When the bleeding is protracted the patients have the more
serious manifestations of loss of blood. In the slow dri^^ping which takes
place in some instances of haemophilia, there may be formed a remarkable
blood tumor projecting from one nostril and extending even below the
mouth.
Death from ordinary epistaxis is very rare. The more blood is lost,
the greater is the tendency to clotting with spontaneous cessation of the
bleeding.
The diagnosis is usually easy. One point only need be mentioned ;
namely, that bleeding from the posterior nares occasionally occurs during
sleep and the blood trickles into the pharynx and may be swallowed. If
vomited, it may be confounded with haematemesis ; or, if coughed up, with
haemoptysis.
Treatm.ent. — In a majority of the cases the bleeding ceases of itself.
Various simple measures may be employed, such as holding the arms
above the head, the application of ice to the nose, or the injection of cold
or hot water into the nostrils. Astringents, such as zinc, alum, or tannin,
may be used ; and the old-fashioned and sometimes successful remedy, a
cobweb, may be introduced into tlie nostrils. If the bleeding comes from
an ulcerated surface, an attempt should be made to apply chromic acid or
to cauterize. If the bleeding is at all severe and obstinate, the posterior
nares should be plugged. Ergot may be given internally or hypodermi-
cally.
480 DISEASES OF THE RESPIRATORY SYSTEM.
II. DISEASES OF THE LAEYNX.
I. ACUTE CATARRHAL LARYNGITIS.
This may come on as an independent affection or in association with
general catarrh of the upper respiratory passages.
Etiology. — Many cases are due to catching cold or to overuse of the
voice ; others develop in consequence of the inhalation of irritating gases.
It may occur in the general catarrh associated with influenza and measles.
Very severe laryngitis is excited by traumatism, either injuries from with-
out or the lodgment of foreign bodies. It may be caused by the action of
very hot liquids or corrosive poisons.
Symptoms. — There is a sense of tickling referred to the larynx;
the cold air irritates and, owing to the increased sensibility of the mucous
membrane, the act of inspiration may be painful. There is a dry cough,
and the voice is altered. At first it is simply husky, but soon phonation
becomes painful, and finally the voice may be completely lost. In adults
the respirations are not increased in frequency, but in children dyspnoea
is not uncommon and may occur in spasmodic attacks. If much oedema
accompanies the inflammatory swelling, there may be urgent dyspnoea.
The laryngoscope shows a swollen and tumefied mucous membrane of
the larynx, particularly the ary-epiglottidean folds. The vocal cords
have lost their smooth and shining appearance and are reddened and
swollen. Their mobility also is greatly impaired, owing to the infiltration
of the adjoining mucous membrane and of the muscles. A slight mucoid
exudation covers the parts. The constitutional symptoms are not severe.
There is rarely much fever, and in many cases the patient is not seriously
ill. Occasionally cases come on with greater intensity, the cough is very
distressing, deglutition is painful, and there may be urgent dyspnoea.
Diagnosis. — There is rarely any difficulty in determining the nature
of a case if a satisfactory laryngoscopic examination can be made. The
severer forms may simulate oedema of the glottis. When the loss of voice
is marked, the case may be mistaken for one of nervous aphonia, but the
laryngoscope would decide the question at once. Much more difficult is
the diagnosis of acute laryngitis in children, particularly in the very
young, in whom it is so hard to make a proper examination. From ordi-
nary laryngismus it is to be distinguished by the presence of fever, the
mode of onset, and particularly the coryza and the previous symptoms of
hoarseness or loss of voice. Membranous laryngitis may at first be quite
impossible to differentiate, but in a majority of cases of this affection there
are patches on the pharynx and early swelling of the cervical glands. The
symptoms, too, are much more severe.
Treatm.ent. — Rest of the larynx should be enjoined, so far as pho-
nation is concerned. In cases of any severity the patient should be kept
CEDEMATOUS LARYNGITIS. 481
in bed. The room should be at an even temperature and the air satu-
rated with moisture. Early in the disease, if there is much fever, aconite
and citrate of potash can be given, and for the irritating painful cough a
full dose of Dover's powder at night. An ice-bag externally often gives
great relief.
II. CHRONIC LARYNGITIS.
Etiology. — The cases usually follow repeated acute attacks. The
most common causes are overuse of the voice, particularly in persons
whose occupation necessitates shouting in the open air. The con-
stant inhalation of irritating substances, as tobacco-smoke, may also
cause it.
Symptoms. — The voice is usually hoarse and rough and in severe
cases may be almost lost. There is usually very little pain ; only the un-
pleasant sense of tickling in the larynx, which causes a frequent desire to
cough. AYith the largyngoscope the mucous membrane looks swollen, but
much less red than in the acute condition. In association with the granu-
lar pharyngitis, the mucous glands of the epiglottis and of the ventricles
may be involved.
Treatm.ent. — The nostrils should be carefully examined, since in
some instances chronic laryngitis is associated with and even dependent
upon obstruction to the free passage of air through the nose. Local appli-
cation must be made directly to the larynx, either with a brush or by
means of a spray. Among the remedies most recommended are the solu-
tions of nitrate of silver, chlorate of potash, perchloride of zinc, and tannic
acid. Insufflations of bismuth are sometimes useful.
Among directions to be given are the avoidance of heated rooms and
loud speaking, and abstinence from tobacco and alcohol. The throat
should not be too much muffled, and morning and evening the neck should
be sponged with cold water.
III. CEDEMATOUS LARYNGITIS.
Etiology. — CEdema of the glottis, or, more correctly, of the struct-
ures which form the glottis, is a very serious affection which is met with
(a) as a rare sequence of ordinary acute laryngitis, whether due to cold or
to the application of irritants, (h) In chronic diseases of the larynx, as
syphilis or tubercle, (c) In severe inflammatory diseases like diphtheria,
in erysipelas of the neck, and in various forms of cellulitis, (d) Occa-
sionally in the acute infectious diseases — scarlet fever, typhus, or typhoid.
In I>right's disease, either acute or chronic, there may be a rapidly devel-
oping (jedema. The connection with Bright's disease has been disputed
and is certainly rare. I have met with two instances, one in scarlatinal
482 DISEASES OF THE RESPIRATORY SYSTEM.
nephritis and tlie other in chronic interstitial nephritis. Both cases
proved fatal in a short time.
Symptoms. — There is dyspnoea, increasing in intensity, so that with-
in an hour or two the condition becomes very serious. There is sometimes
marked stridor in respiration. Tlie voice becomes husky and disappears.
The laryngoscope shows enormous swelling of the epiglottis, which can
sometimes be felt with the finger or even seen when the tongue is strongly
depressed with a spatula. The ary-epiglottidean folds are the seat of the
chief swelling and may almost meet in the middle line. Occasionally the
oedema is below the true cords.
The diagnosis is rarely difficult, inasmuch as even without the laryn-
goscope the swollen epiglottis can be seen or felt with the finger. The
disease is very fatal.
Treatm.ent. — An ice-bag should be placed on the larynx and the
patient given ice to suck. If the symptoms are urgent, the throat should
be sprayed with a strong solution of cocaine, and the swollen epiglottis
scarified. If relief does not follow, tracheotomy should immediately be
performed. The high rate of mortality is due to the fact that this opera-
tion is as a rule too long delayed.
IV. MEMBRANOUS LARYNGITIS {Croup),
Inflammation of the larynx, with membranous exudation occurs: (1)
As a simple, non-specific, non-contagious affection, local in its nature, and
not occurring in epidemics. It is unquestionably a rare disease. (2) As
an effect of diphtheria, in which the disease may be limited to the lar}Tix,
but most commonly is associated with exudation on the pharynx oi*
tonsils.
Etiology. — Membranous croup is now regarded by many authorities
as always diphtheritic, and while it must be acknowledged that this is so
in the great majority of instances, there are cases, few in number, it is
true, in which it is not possible to assign this origin. The question may
be settled by the presence or absence of Loeffler's bacillus, which is a
definite criterion of diphtheritic pseudo-membrane. At the Montreal
General Hospital, which received annually an exceptionally large number
of cases of diphtheria, we were in the habit of regarding all the laryngeal
cases as true diphtheria, even when no patches could be seen on the ton-
sils. On several occasions, in cases of this kind, I have been able to de-
monstrate post mortem that the exudation had extended at the back of
the tonsils or on the posterior pillars of the fauces. On the other hand,
twice at the Infant's Home I saw cases, sporadic in their nature, com-
ing on suddenly without much fever, with extensive fibrinous exuda-
tion, necessitating tracheotomy, but without a trace of pharyngeal exuda-
tion. Although the conditions were most favorable for the spread of
MEMBRANOUS LARYNGITIS. 483
the infection in the Home, no other cases occurred. Provisionally, at
any rate, I still hold that there is a separate independent affection, a non-
contagious membranous croup. Yet I am willing to acknowledge that
the large majority of the cases of fibrinous laryngitis are due to the poi-
son of diphtheria. It is particularly desirable that a bacteriological ex-
amination should be made of the membrane in the former class of cases.
The disease affects young children, particularly between the ages of two
and six. Cases under two and over seven are very rare. Statistics show
that boys are more often attacked than girls Cases occur occasionally
with scarlet fever and measles.
Morbid Anatomy. — On inspection of the larynx of a child dead of
membraneous croup, the rima is seen filled with mucus or with a shreddy
material which, when washed off carefully, leaves the mucosa covered by a
thin grayish-yellow membrane, which may be uniform or in patches. It
covers the ary-epiglottic folds and the true cords, and may be continued
into the ventricles or even into the trachea. Above, it may involve the
epiglottis. It varies much in consistency. I have seen fatal cases in
which the exudation was not actually membranous, but rather friable and
granular. It may form a thick, even stratified membrane, which fills the
entire glottis. The exudation may extend down the trachea and into the
bronchi, and may pass beyond the epiglottis to the fauces. Usually it can
be readily stripped off from the mucous membrane of the larynx and leaves
exposed the swollen and injected mucosa. On examination it is seen that
the fibrinous material has involved chiefly the epithelial lining and has not
greatly infiltrated the subjacent tissues.
Symptoms. — Naturally, the clinical symptoms are almost identical in
the non-specific and specific forms of membranous laryngitis.
The affection begins like an acute laryngitis with slight hoarseness and
rough cough, to which the term croupy has been applied. After these
symptoms have lasted for a day or two with varying intensity, the child
suddenly becomes worse, usually at night, and there are signs of impeded
respiration. At first the difficulty in breathing is paroxysmal, due proba-
bly to more or less spasm of the muscles of the glottis. Soon the dyspnoea
becomes continuous, inspiration and expiration become difficult, particularly
the latter, and with the inspiratory movements the epigastrium and lower
intercostal spaces are retracted. The voice is husky and may be reduced
to a whisper. The color gradually changes and the imperfect aeration of
the blood is shown in the lividity of the lips and finger-tips. Eestlessness
comes on and the child tosses from side to side, vainly trying to get breath.
Occasionally, in a severer paroxysm, portions of membrane are coughed out.
The fever in non-specific membranous laryngitis is rarely high and the
condition of the child is usually very good at the time of the onset. The
pulse is always increased in frequency and if cyanosis be present is small.
In favorable cases the dyspnoea is not very urgent, the color of the face
remains good, and after one or two paroxysms the child goes to sleep and
484 DISEASES OF THE RESPIRATORY SYSTEM.
wakes in the morning, perhaps without fever and feeling comfortable.
The attack may recur the following night with greater severity. In un-
favorable cases the dyspnoea becomes more and more urgent, the cyanosis
deepens, the child, after a period of intense restlessness, sinks into a semi-
comatose state, and death finally occurs from poisoning of the nerve centres
by carbon dioxide. In diphtheritic laryngitis the onset is usually less sud-
den and is preceded by a longer period of indisposition. As a rule, there
are pharyngeal symptoms. The constitutional disturbance, too, is more
severe, the fever higher, and there may be swelling of the glands of the
neck. Inspection of the fauces may show the presence of false membranes
on the pillars or on the tonsils. This, however, is held by some not to be
an invariable evidence of the diphtheritic nature of the inflammation.
Fagge held that non-contagious membranous croup may spread upward
from the larynx just as diphtheritic inflammation is in the habit of spread-
ing downward from the fauces. Ware, of Boston, whose essay on croup is
perhaps the most solid contribution to the subject made in this country,
reported the presence of exudate in the fauces in 74 out of 75 cases of croup.
These observations w^ere made prior to 1840, during periods in which
diphtheria was not epidemic to any extent in Boston. In protracted
cases pulmonary symptoms may develop, which are sometimes due to the
difficulty in expelling the muco-pus from the tubes ; in others, the false
membrane extends into the trachea and even into the bronchial tubes.
During the paroxysm the vesicular murmur is scarcely audible, but the
laryngeal stridor may be loudly communicated along the bronchial tubes.
Diagnosis. — Membranous laryngitis must be distinguished from
ordinary simple laryngitis and from certain spasmodic affections. Simple
catarrhal laryngitis rarely induces such severe symptoms, occurs more sud-
denly, nearly always at night, and the hoarseness and implication of the
voice are not nearly so marked. The presence of preceding symptoms is
one of the most important diagnostic distinctions between the false and the
true croup. By hoarseness, dyspnoea, and signs of membrane on the fauces
or tonsils the existence of membranous laryngitis may be definitely deter-
mined. Occasionally simple laryngitis induces swelling sufficient to cause
marked dyspnoea and hoarseness and may, indeed, prove fatal. Of course,
true membranous laryngitis may follow the catarrhal form. In laryngis-
mus the attack comes on suddenly and is not associated with either cough
or hoarseness. The child is seized with a difficulty in breathing ; the in-
spirations are crowing in character, and the dyspnoea rapidly becomes
urgent, so that symptoms of suffocation supervene, sometimes within less
than a minute ; the spasm then relaxes and the child appears to be in its
normal condition. It is most commonly met with in rickety children.
The diagnosis between diphtheritic and non-diphtheritic membranous
laryngitis is by no means easy, and, as mentioned above, many excellent au-
thorities hold the diseases to be identical. The following are the chief points
of distinction, which refer to general rather than to local conditions ; The
MEMBRANOUS LARYNGITIS. 485
non-specific affection generally begins in the larynx and the fauces are but
slightly, if at all, affected. It is not infectious. Cases develop in institu-
tions under circumstances most favorable to the spread of the disease, but
other children are not attacked. It has none of the serious asthenic symp-
toms of diphtheria, and it is not followed by paralysis. It occurs almost
exclusively in very young children, whereas diphtheritic laryngitis is not
at all uncommon in adults.
Prognosis. — True croup, whether simple or diphtheritic, with a mor-
tality of from sixty to eighty per cent, is an extremely fatal disease. When
it attacks healthy children and is not secondary to some febrile affection,
the outlook is more hopeful. Even a very limited exudation may prove
fatal. On several occasions, in performing post-mortems in fatal cases, I
have been astonished to find such a slight involvement of the larynx ; in
some instances scarcely more than a granular exudation covering the
cords and folds. A fatal result is almost inevitable when the disease ex-
tends to the bronchi.
Treatment. — As the cases rarely come under observation until the
membrane is formed, the main medicinal indication is to favor its separa-
tion. The air of the room should be saturated with moisture from an
atomizer and the throat should be sprayed with lime-water.
In young children topical application to the larjmx itself is extremely
difficult and in many instances impossible. Good results have followed
the passage of a sponge-probang with a strong solution of nitrate of silver.
It is an easy matter to recommend such measures, but very difficult to
carry them out. The administration of a brisk emetic will sometimes
bring away portions of the false membrane ; ipecacuanha or the turpeth
mineral is the most suitable. Of late years there has been a return to the
mercurial treatment of membranous laryngitis, but I have not seen such
results from its use as would justify a recommendation of it. Continuous
hot applications to the throat are usually much more grateful than the
ice-bag, so highly recommended by some practitioners. With the first
indication of defective aeration of the blood it is well to let the child in-
hale oxygen, which may be conveniently passed into a tent made of sheets
on the bed.
In very many cases the obstruction reaches such a grade that the pro-
priety of intubation or tracheotomy is raised. One great advantage of
the former is that it may be suggested at an earlier stage with more like-
lihood of gaining the consent of the parents.
The statistics of tracheotomy are not very satisfactory, as only a fourth
to a third of the cases recover.
The general treatment of these cases is of great importance. In the
first place the child should be isolated, since it is often impossible to say
whether the case is specific or not. Much of the success in the case de-
pends upon careful nursing. There is no disease which requires greater
care, coolness, and judgment on the part of the attendants. The diet
4:86 DISEASES OF THE RESPIRATORY SYSTEM.
should consist of milk and beef -juices. Water should be given freely to
the child, and if the pulse shows signs of failing, stimulants should at once
be administered. The extreme restlessness calls for anodynes, but they
must be administered with great care ; bromide and chloral are to be pre-
ferred to opium. In cases in which the dyspnoea comes on in paroxysms,
as if due to spasm, I have seen great benefit follow the inhalation of
chloroform.
V. SPASMODIC LARYNGITIS {Laryngismus sfridulus).
Spasm of the glottis is met with in many affections of the larynx, but
there is a special disease in children which has received the above-men-
tioned names.
Etiology. — A purely nervous affection, without any inflammatory
condition of the larynx, it occurs in children between the ages of six
months and three years, and is most commonly seen in connection with
rickets. It is also associated with tetany. Often the attack comes on
when the child has been crossed or scolded. Mothers sometimes call the
attacks " passion fits " or attacks of " holding the breath." It was sup-
posed at one time that they were associated with enlargement of the
thymus, and they therefore received the name of thymic asthma.
The actual condition of the larynx during a paroxysm is a spasm of the
adductors, but the precise nature of the influences causing it is not yet
known, whether centric or reflex from peripheral irritation. The disease
is not so common in America as in England.
Symptoms. — The attacks may come on either in the night or in the
day ; often just as tlie child awakes. There is no cough, no hoarseness,
but the respiration is arrested and the child struggles for breath, the face
gets congested, and then, with a sudden relaxation of the spasm, the air
is drawn into the lungs with a high-pitched crowing sound, which has
given to the affection the name of "child-crowing." 'Convulsions may
occur during an attack or there may be carpo-pedal spasms. Death may,
but rarely does, occur during the attack. With the cyanosis the spasm
relaxes and respiration begins. The attacks may recur with great fre-
quency throughout the day.
Treatm.ent. — The gums should be carefully examined and, if swol-
len and hot, freely lanced. The bowels should be carefully regulated
and as these children are usually delicate or rickety nourishing diet and
cod-liver oil should be given. By far the most satisfactory method of
treatment is the cold sponging. In severe cases, two or three times a day
the child should be placed in a warm bath and the back and chest thor-
oughly sponged for a minute or two with cold water. Since learning this
practice from Ringer, at the University Hospital, I have seen many cases
in which it proved successful. It may be employed when ths child is in
TUBERCULOUS LARYNGITIS. 4S7
a paroxysm, though if the attack is severe and the lividity is great it is
much better to dash cold water into the face. Sometimes tlie introduc-
tion of the finger far back into the throat will relieve the spasm.
Spasmodic croup, believed to be a functional spasm of the muscles of
the larynx, is an alfection seen most commonly between the the ages of
two and five years. According to Trousseau's description, the child goes
to bed well, and about midnight or in the early morning hours awakes with
oppressed breathing, harsh, croupy cough, and perhaps some huskiness of
voice. The oppression and distress for a time are very serious, the face is
congested, and there are signs of approaching cyanosis. The attack passes
off abruptly, the child falls asleep and awakes the next morning feeling
perfectly well. These attacks may be repeated for several nights in suc-
cession, and usually cause great alarm to the parents. Whether this is en-
tirely a functional spasm is, I think, doubtful. There are instances in
which the child is somewhat hoarse through the day, and has slight ca-
tarrhal symptoms and a brazen, croupy cough. There is probably slight
catarrhal laryngitis with it. These cases are not infrequently mistaken
for true croup, and parents are sometimes unnecessarily disturbed by the
serious view which the physician takes of the case. Too often the poor
child, deluged with drugs, is longer in recovering from the treatment than
he would be from the disease. To allay the spasm a whiff of chloroform
may be administered, which will in a few moments give relief, or the child
may be placed in a hot bath. A prompt emetic, such as zinc or wine of
ipecac, will usually relieve the spasm, and is specially indicated if the child
has overloaded the stomach through the day.
VL TUBERCULOUS LARYNGITIS.
Etiolog'y. — Tubercles may develop primarily in the laryngeal mucosa,
but in the great majority of cases the affection is secondary to pulmonary
tuberculosis, in which it is met with in a variable proportion of from
eighteen to thirty per cent, ^fales are more frequently affected than
females, possibly, as Bosworth suggested, because they are more frequently
subject to catarrhal laryngitis, which is undoubtedly a predisposing cause.
Laryngitis may occur very early in pulmonary tuberculosis. There may
be well-marked involvement of the larynx with signs of very limited trouble
at one apex. These are cases which, in my experience, run a very unfavor-
able course.
Morbid Anatomy. — The mucosa is at first swollen and presents
scattered tubercles, which seem to begin in the neighborhood of the blood-
vessels. By their fusion small tuberculous masses arise, which caseate and
finally ulcerate, leaving shallow irregular losses of substance. The ulcers
are usually covered with a grayish exudation, and there is a general thick-
ening of the mucosa about them, which is particularly marked upon the
488 DISEASES OF THE RESPIRATOIIY SYSTEM.
arytenoids. The ulcers may erode the true cords and finally destroy them,
and passing deeply may cause perichondritis with necrosis and occasionally
exfoliation of the cartilages. The disease may extend laterally and involve
the pharynx, and downward over the mucous membrane covering the
cricoid cartilage toward the oesophagus. Above, it may reach the posterior
wall of the pharynx, and in rare cases extend to the fauces and tonsils.
The epiglottis may be entirely destroyed. There are rare instances in
which cicatricial changes go on to such a degree that stenosis of the larynx
is induced, a remarkable specimen of which I saw some years ago with
J. Solis-Cohcn.
Symptoms. — The first indication is slight huskiness of the voice,
which finally deepens to hoarseness, and in advanced stages there may be
complete loss of voice. There is something very suggestive in the early
hoarseness of tuberculous laryngitis. My attention has frequently been
directed to the lungs simply by the quality of the voice.
The cough is in part due to involvement of the larynx. Early in the
disease it is not very troublesome, but when the ulceration is extensive it
becomes husky and ineffectual. Of the symptoms of laryngeal tubercu-
losis, none is more aggravating than the dysphagia, which is met with par-
ticularly when the epiglottis is involved, and when the ulceration has
extended to the pharynx. There is no more distressing or painful compli-
cation in phthisis. In instances in which the epiglottis is in great part
destroyed, with each attempt to take food there are distressing paroxysms
of cough, and even of suffocation.
With the laryngoscope there is seen early in the disease a pallor of the
mucous membrane, which also looks thickened and infiltrated, particularly
that covering the arytenoid cartilages. The tuberculous ulcers are very
characteristic. They are broad and shallow, with gray bases and ill-defined
outlines. The vocal cords are infiltrated and thickened, and ulceration is
very common.
The diagnosis of tuberculous laryngitis is rarely difficult, as it is usu-
ally associated with well-marked pulmonary disease. In case of doubt
some of the secretion from the base of an ulcer should be removed and
examined for bacilli.
Treatm.ent. — Physicians pay scarcely sufficient attention to the
laryngeal complications of consumption. The ulcers should be sprayed
and kept thoroughly cleansed. Solutions of tannic acid, nitrate of silver,
or sulphide of zinc may be employed. The insufflation, two or three times
a day, of a powder of iodoform, with morphia, after thoroughly cleansing
the ulcers witli a spray, relieves the pain in a majority of the cases. Co-
caine (four per cent solution) applied with the atomizer will often enable
the patient to swallow his food comfortably. There are, however, distress-
ing cases of extensive laryngeal and pharyngeal ulceration in which even
cocaine loses its good effects. When the epiglottis is lost the difficulty in
swallowing becomes very great. Wolfenden states that this may be obvi-
SYPniLITIO LARYNGTTTS. 489
atecl if the patient liangs liis head over the side of the bed and sucks milk
through a rubber tubing from a mug placed on the floor.
VII. SYPHILITIC LARYNGITIS.
Syphilis attacks the larynx with great frequency. It may result from
the inherited disease or be a secondary or tertiary manifestation of the ac-
quired form.
Symptoms. — In secondary syphilis there is occasionally erythema of
the larynx, which may go on to definite catarrh, but has nothing charac-
teristic. The process may proceed to the formation of superficial whitish
ulcers, usually symmetrically placed on the cords or ventricular bands.
Mucous patches and condylomata are rarely seen. The symptoms are
practically those of slight loss of voice with laryngeal irritation, as in the
simple catarrhal form.
The tertiary laryngeal lesions are numerous and very serious. True
gummata, varying in size from the head of a pin to a small nut, develop
in the submucous tissue most commonly at the base of the epiglottis.
They go through the changes characteristic of these structures and may
either break down, producing extensive and deep ulceration, or — and this
is more characteristic of syphilitic laryngitis — in their healing form a
fibrous tissue which shrinks and produces stenosis. The ulceration is apt
to extend deeply and involve the cartilage, inducing necrosis and exfolia-
tion, and even haemorrhage from erosion of the arteries. (Edema may
suddenly prove fatal. The cicatrices which follow the sclerosis of the
gummata or the healing of the ulcers produce great deformity. The epi-
glottis, for instance, may be tied down to the pharyngeal wall or to the
epiglottic folds, or even to the tongue ; and eventually a stenosis results,
which may necessitate tracheotomy.
The laryngeal symptoms of inherited syphilis have the usual course of
these lesions and appear either early, within the first five or six months, or
after puberty ; most commonly in the former period. Of 76 cases, J. N.
Mackenzie found that 63 occurred within the first year. The gummatous
infiltration leads to ulceration, most commonly of the epiglottis and in
the ventricles, and the process may extend deeply and involve the carti-
lage. Cicatricial contraction may also occur.
The diagnosis of syphilis of the larynx is rarely difficult, since it
occurs most commonly in connection with other symptoms of the
disease. For special details the manuals of laryngology should be con-
sulted.
Treatm.ent. — The administration of constitutional remedies is the
most important, and under mercury and iodide of potassium the local
symptoms may rapidly be relieved. The tertiary laryngeal manifestations
are always serious and difficult to treat. The deep ulceration is specially
82
490 DISEASES OF THE RESPIRATORY SYSTEM.
hard to combat, and the cicatrization may necessitate tracheotomy, or the
gradual dilatation, as practised by Schroetter.
III. DISEASES OF THE BKONCHI.
I. ACUTE BRONCHITIS.
Acute catarrhal inflammation of the bronchial mucous membrane is a
very common disease, rarely serious in healthy adults, but very fatal in the
old and in the young, owing to associated pulmonary complications. It is
bilateral and aifects either the larger and medium sized tubes or the
smaller bronchi, in which case it is known as capillary bronchitis.
We shall speak only of the former, as the latter is part and parcel of
broncho-pneumonia.
Etiology. — Acute bronchitis is a common sequence of catching cold,
and is often nothing more than the extension downward of an ordinary
coryza. It occurs most frequently in the changeable weather of early
spring and late autumn. Its association with cold is well indicated by
the popular expression " cold on the chest." It may prevail as an epi-
demic apart from influenza, of which it is an important feature.
Acute bronchitis is associated with many other affections, notably
measles. It is by no means rare at the onset of typhoid fever and malaria.
It is present also in asthma and whooping-cough. The bronchitis of
Bright's disease, gout, and heart-disease is usually a chronic form. It
attacks persons of all ages, but most frequently the young and the old.
There are individuals who have a special disposition to bronchial catarrh,
and the slightest exposure is apt to bring on an attack. Persons who live
an out-of-door life are usually less subject to the disease than those who
follow sedentary occupations.
The affection is probably microbic, though we have as yet no definite
evidence upon this point.
Morbid Anatomy. — The mucous membrane of the trachea and
bronclii is reddened, congested, and covered with mucus and muco-pus,
which may be seen oozing from the smaller bronchi, some of which are
dilated. The finer changes in the mucosa consist in desquamation of the
ciliated epithelium, swelling and oedema of the submucosa, and infiltration
of the tissue with leucocytes. The mucous glands are much swollen.
Symptoms. — The symptoms of an ordinary " cold " accompany the
onset of an acute bronchitis. The coryza extends to the tubes, and may
also affect the larynx, producing lioarseness, which in many cases is marked.
A chill is rare, but there is invariably a sense of oppression, with heavi-
ness and languor and pains in the bones and back. In mild cases there is
scarcely any fever, but in severer forms the range is from 101° to 103°.
ACUTE BRONCHITIS. 491
The bronchial symptoms set in with a feeling of tightness and rawness
beneath the sternum and a sensation of oppression in the chest. The
cough is rough at first, cutting and sore, and often of a ringing character.
It comes on in paroxysms which rack and distress the patient extremely.
During the severe spells the pain may be very intense beneath the sternum
and along the attachments of the diaphragm. At first the cough is dry,
but in a few days the secretion becomes muco-purulent and abundant, and
finally purulent. With the loosening of the cough great relief is experi-
enced. The sputum is made up largely of pus-cells, with a variable number
of the large round alveolar cells, many of which contain carbon grains,
while others have undergone the myelin degeneration.
Physical Sigiis. — The respiratory movements are not greatly increased
in frequency unless the fever is high. There are instances, however, in
which the breathing is rapid and when the smaller tubes are involved
there is dyspnoea. On palpation the bronchial fremitus may often be felt.
On auscultation in the early stage, piping sibilant rales are everywhere to
be heard. They are very changeable, and appear and disappear with cough-
ing. With the relaxation of the bronchial membranes and the greater
abundance of the secretion, the rales change and become mucous and bub-
bling in quality.
The course of the disease depends on the conditions under which it
develops. In healthy adults, by the end of a week the fever subsides and
the cough loosens. In another week or ten days convalescence is fully
established. In young children the chief risk is in the extension of the
process downward. In measles and whooping-cough, the ordinary bron-
chial catarrh is very apt to descend to the finer tubes, which become di-
lated and plugged with muco-pus, inducing areas of collapse, and finally
broncho-pneumonia. This extension is indicated by changes in the physi-
cal signs. Usually at the base the rales are subcrepitant and numerous
and there may be areas of defective resonance and of feeble or distant tu-
bular breathing. In the aged and debilitated there are similar dangers if
the process extends from the larger to the smaller tubes. In old age the
bronchial mucosa is less capable of expelling the mucus, which is more
apt to sag to the dependent parts and induce dilatation of the tubes with
extension of the inflammation to the contiguous air-cells.
The diagnosis of acute bronchitis is rarely difficult. Although the
mode of onset may be brusque and perhaps simulate pneumonia, yet the
absence of dulness and blowing breathing, and the general character of
the bronchial inflammation, renders the diagnosis simple. The complica-
tion of broncho-pneumonia is indicated by the greater severity of the symp-
toms, particularly the dyspnoea, the defective color, and the physical signs.
Treatment. — In mild cases, household measures suffice. The hot
foot-bath, or the warm bath, a drink of hot lemonade, and a mustard plas-
ter on the chest will often give relief. For the dry, racking cough, the
symptom most complained of by the patient, Dover's powder is the best
49^ DISEASES OF THE RESPIRATORY SYSTEM.
remedy. It is a popular belief that quinine, in full doses, will check an
oncoming cold in the chest, but this is doubtful. It is a common custom
when persons feel the approach of a cold to take a Turkish bath, and
though the tightness and oppression may be relieved by it, there is in a
majority of the cases great risk. Some of the severest cases of bronchitis
which I have seen have followed this initial Turkish bath. No doubt, if
the person could go to bed directly from the bath, its action would be
beneficial, but there is great risk of catching additional " cold " in going
home from the bath. Eelief is obtained from the unpleasant sense of
rawness by keeping the air of the room saturated with moisture, and in
this dry stage the old-fashioned mixture of the wines of antimony and ipe-
cacuanha with liquor ammonias acetatis and nitrous ether is useful. If
the pulse is very rapid, tincture of aconite may be given, particularly in
the case of children. For the cough, when dry and irritating, opium
should be freely used in the form of Dover's powder. Of course, in the
very young and the aged care must be exercised in the use of opium, par-
ticularly if the secretions are free ; but for the distressing, irritative cough,
which keeps the patient awake, no remedy can take its place As the cough
loosens and the expectoration is more abundant, the patient becomes more
comfortable. In this stage it is customary to ply the patient with expec-
torants of various sorts. Though useful occasionally, they should not be
given as a matter of routine. A mixture of squills, ammonia, and senega
is a favorite one with many practitioners at this stage.
In the acute bronchitis of children, if the amount of secretion is large
and difficult to expectorate, or if there is dyspncea and the color begins
to get dusky, an emetic (a tablespoonful of ipecac wine) should be given
at once and repeated if necessary.
II. CHRONIC BRONCHITIS.
Etiology. — This affection may follow repeated attacks of acute bron-
chitis, but it is most commonly met with in chronic lung affections, heart-
divsease, gout, and renal disease. It is frequent in the aged ; the young
rarely are affected. Climate and season have an important influence. It
is the winter cough of the old man, which recurs with regularity as the
weather gets cold and changeable.
Morbid Anatomy. — The bronchial mucosa presents a great variety
of changes, depending somewhat upon the disease with which chronic
bronchitis is associated. In some cases the mucous membrane is very
thin, so that the longitudinal bands of elastic tissue stand out prominently.
Tlie tubes are dilated and the muscular and glandular tissues are atrophied
and the epithelium in great part shed.
In other instances the mucosa is thickened, granular, and infiltrated.
There may be ulceration, particularly of the mucous follicles. Bronchial
CHRONIC BRONCHITIS. 493
dilatations are not uncommon and emphysema is a constant accompani-
ment.
Symptoms. — In the form met with in old men, associated with em-
physema, gout, or heart-disease, the chief symptoms are as follows : Short-
ness of breath, which may not be noticeable except on exertion. The
patients " puff and blow " on going up hill or up a flight of stairs. This is
due not so much to the chronic bronchitis itself as to associated emphysema
or even to cardiac weakness. They complain of no pain. The cough is varia-
ble, changing with the weather and with the season. During the summer
they may remain free, but each succeeding winter the cough comes on with
severity and persists. There may be only a spell in the morning, or the
chief distress is at night. The sputum in chronic bronchitis is very varia-
ble. In cases of the so-called dry catarrh there is no expectoration. Usu-
ally, however, it is abundant, muco-purulent, or distinctly purulent in
character. There are instances in which the patient coughs up for years
a thin fluid sputum. There is rarely fever. The general health may be
good and the disease may present no serious features apart from the lia-
bility to induce emphysema and bronchiectasy. In many cases it is an
incurable affection. Patients improve and the cough disappears in the
summer time only to return during the winter months.
Physical Signs. — The chest is usually distended, the movements are
limited, and the condition is often that which we see in emphysema. The
percussion note is clear or hyperresonant. On auscultation, expiration is
prolonged and wheezy and rhonchi of various sorts are heard — some high-
pitched and piping, others deep-toned and snoring. Crepitation is com-
mon at the bases.
Clinical Varieties. — The description just given is of the ordinary
chronic bronchitis which occurs in connection with emphysema and heart-
disease and in many elderly men. There are certain forms which merit spe-
cial description : (a) On several occasions I have met with a form of chronic
bronchitis, particularly in women, which comes on between the ages of
twenty and thirty and may continue indefinitely without serious impair-
ment of the health. In one case, a lady of fifty, with a phthisical family
history, began to cough when she was twenty-five, and since then has had
more or less cough every day without intermission. It has not seriously
impaired her health, though she has never been strong. Once or twice
she has had attacks of eczema. The cough is chiefly in the morning, is
apt to be brought on by too much conversation, and is quite independent
of the weather. The daily amount of expectoration is not great, rarely
more than from four to six ounces. It is muco-purulent in character.
The examination of the chest is negative — no emphysema, no rilles. I
have met several such instances which seem to form a type of chronic
bronchitis, though it is difficult to say upon what the condition depends.
(fj) Bronchorrhma. — Excessive bronchial secretion is met witli under
several conditions. It must not be mistaken for the profuse expectoration
494 DISEASES OP THE RESPIRATORY SYSTEM.
of broncliiectasy. The secretion may be very liquid and watery — hronclior-
rhcea serosa. More commonly, it is purulent though thin, and with green-
ish or yellow-green masses. It may be thick and uniform. This profuse
bronchial secretion is usually a manifestation of chronic bronchitis and
may lead to dilatation of the tubes and ultimately to fetid bronchitis. In
the young the condition may persist for years without impairment of
health and without apparently damaging the lungs.
{c) Putrid Bronchitis. — Fetid expectoration is met with in connection
with bronchiectasis, gangrene, abscess, or with decomposition of secretions
within phthisical cavities and in an empyema which has perforated the
lung. There are instances in which, apart from any of these states, the
expectoration has a fetid character. The sputa are abundant, usually
thin, grayish white in color, and they separate into an upper fluid layer
capped with frothy mucus and a thick sediment in which may sometimes
be found dirty yellow masses the size of peas or beans — the so-called Dit-
trich's plugs. The affection is very rare apart from the above-mentioned
conditions. In severe cases it leads to changes in the bronchial walls,
pneumonia, and often to abscess or gangrene. Metastatic brain abscess
has followed putrid bronchitis in a certain number of cases.
{d) Dry Catarrh. — Catarrhe sec of Laennec is a not uncommon form,
characterized by paroxysms of coughing of great intensity, with little or
no expectoration. It is usually met with in elderly persons with emphy-
sema, and is one of the most chronic and obstinate of all varieties of bron-
chitis.
Treatment. — By far the most satisfactory method of treating the
recurring winter bronchitis is change of climate. Eemoval to a southern
latitude may prevent the onset. Southern France, southern California,
and Florida furnish winter climates in which the subjects of chronic
bronchitis live with the greatest comfort. All cases of prolonged bronchial
irritation are benefited by change of air.
The first endeavor in treating a case of chronic bronchitis is to ascer-
tain if possible whether there are constitutional or local affections with
which it is associated. In many instances the urine is found to be highly
acid, perhaps slightly albuminous, and the arteries are stiff. In the form
associated with this condition, sometimes called gouty bronchitis, the at-
tacks seem related to tlie defective renal elimination, and to this condition
the treatment should be first directed. In other instances there are heart-
disease and emphysema. In the form occurring in old men much may be
done in the way of prophyhixis. Septuagenarians should read Oliver Wen-
dell Holmes's * " I)e Senectute " with reference to the care of the health
and the avoidance of catching cold. He lays stress upon the importance
of the daily study of tlie thermometer and barometer. There is no doubt
that with prudence even in our changeable winter weather much may be
* Over the Tea-cups, Boston, 1890.
BRONCIIIFX'TASIS. 495
done to prevent the onset of chronic bronchitis. Woolen undergarments
should be used and especial care should be taken in the spring months not
to change them for ligliter ones before the warm weather is established.
Cure is seldom effected by medicinal remedies. There are instances in
which iodide of potassium acts with remarkable benefit, and it should
always be given a trial in cases of paroxysmal bronchitis of obscure origin.
When the secretion is excessive the muriate of ammonia is perhaps the
most useful. Stimulating expectorants are contra-indicated. When the
heart is feeble, the combination of digitalis and strychnia is very bene-
ficial. Turpentine, the old-fashioned remedy so warmly recommended by
the Dublin physicians, has in many quarters fallen undeservedly into dis-
use. Terebene in capsules is a useful substitute because it is more easily
taken. Of other balsamic remedies, sandalwood, the compound tincture
of benzoin, copaiba, balsam of Peru or tolu may be used. Inhalations are
often very useful. If fetor be present, carbolic acid in the form of spray
(twenty to thirty per cent solution) will lessen the odor, or thymol (1 to
1,000). In full-blooded men, when venous engorgement exists and short-
ness of breath, the abstraction of twenty to thirty ounces of blood will
afford prompt relief.
III. BRONCHIECTASIS.
Etiology. — Dilatation of the bronchi occurs under the following
conditions : (1) As a congenital defect or anomaly. Such cases are ex-
tremely rare, commonly unilateral. Grawitz has described the condition
as bro7ichiectasis universalis. Welch has met an instance in a young
girl. (2) In connection with inflammation of the bronchi, particularly
when this leads to weakness of the walls with the accumulation of secre-
tion. Under this category come the dilatation met with in chronic bron-
chitis and emphysema, the dilated bronchi in chronic phthisis, in the
catarrhal pneumonias of children, and particularly the dilitation which
results from the presence of foreign bodies in the air-tubes or from
pressure, as of an aneurism on one bronchus. (3) In extreme contraction
of the lung tissue, whether due to interstitial pneumonia or to compres-
sion by pleural adhesions, bronchial dilatation is a common though not
a constant accompaniment.
Unquestionably the weakening of the bronchial wall is the most impor-
tant, probably the essential, factor in inducing bronchiectasy, since the wall
is then not able to resist the pressure of air in severe spells of coughing
and in straining. In some instances the mere weight of the accumulated
secretion may be sufficient to distend the terminal tubules, as is seen in
compression of a bronchus by aneurism.
Morbid Anatomy. — Two chief forms are recognized — the cylin-
drical and the .saccular — which may exist together in the same lung. The
496 DISEASES OF THE RESPIRATORY SYSTEM.
condition may be general or partial. Universal bronchiectasis is always
unilateral. It occurs in rare congenital cases and is occasionally seen as a
sequence of interstitial pneumonia. The entire bronchial tree is repre-
sented by a series of sacculi opening one into the other. The walls are
smooth and possibly without ulceration or erosion except in the dependent
parts. The lining membrane of the sacculi is usually smooth and glisten-
ing. The dilatations may form large cysts immediately beneath the
pleura. Intervening between the sacculi is a dense cirrhotic lung tissue.
The partial dilatations — the saccular and cylindrical — are common in
chronic phthisis, particularly at the apex, in chronic pleurisy at the base,
and in emphysema. Here the dilatation is more commonly cylindrical,
sometimes fusiform. The bronchial mucous membrane is much in-
volved and sometimes there is a narrowing of the lumen. Occasionally
one meets with a single saccular bronchiectasy in connection with chronic
bronchitis or em.physema. Some of these look like simple cysts, with
smooth walls, without fluid contents.
Histologically the bronchi which are the seat of dilatation show im-
portant changes. In the large, smooth dilatations the cylindrical is re-
placed by a pavement epithelium. The muscular layer is stretched, atro-
phied, and the fibres separated ; the elastic tissue is also much stretched
and separated. In the large saccular bronchiectasies and in some of the
cylindrical forms, due to retained secretions, the lining membrane is ulcer-
ated. The contents of some of the larger bronchiectatic cavities are hor-
ribly fetid.
Symptoms. — In the limited dilatations of phthisis, emphysema, and
chronic bronchitis, the symptoms are in great part those of the original
disease, and the condition often is not suspected during life.
In extensive saccular bronchiectasy the characters of the cough and
expectoration are distinctive. The patient will pass the greater part
of the day without any cough and then in a severe paroxysm will bring
up a large quantity of sputum. Sometimes change of the position will
bring on a violent attack, probably due to the fact that some of the
secretion flows from the dilatation to a normal tube. The daily spell of
coughing is usually in the morning. The expectoration is in many in-
stances very characteristic. It is grayish or grayish brown in color, fluid,
purulent, with a peculiar acid, sometimes fetid, odor. Placed in a conical
glass, it separates into a thick granular layer below and a thin mucoid in-
tervening layer above, which is capped by a brownish froth. Microscopi-
cally it consists of pus-corpuscles, often large crystals of fatty acids, which
are sometimes in enormous numbers over the field and arranged in
bunches. Iloomatoidin crystals are sometimes present. Elastic fibres are
seldom found except when there is ulceration of the bronchial walls.
Tubercle bacilli are not present. In some cases the expectoration is very
fetid and has all the characters of those described under fetid bronchitis.
Nummular expectoration, such as comes from phthisical cavities, is not
BRONCHIAL ASTHMA. 497
common. Haemorrhage may occur, but in my experience it has been rare.
Abscess of the brain has in a few instances followed the bronchiectasis.
Kheumatoid affections may develop (Gerhardt).
The diagnosis is not possible in a large number of the cases. In the
extensive sacculated forms, unilateral and associated with interstitial pneu-
monia or chronic pleurisy, the diagnosis is easy. There is contraction of
the side, which in some instances is not at all extreme. The cavernous
signs may be chiefly at the base and may vary according to the condition
of the cavity, whether full or empty. There may be the most exquisite
amphoric phenomena and loud resonant rales. The condition persists for
years and is not inconsistent with tolerably active life. The patients fre-
quently show signs of marked embarrassment of the pulmonary circula-
tion. There is cyanosis on exertion, the finger-tips are clubbed, and the
nails incurved. A condition very difficult to distinguish from bronchiec-
tasy is a limited pleural cavity communicating with a bronchus.
Treatment. — Medical treatment is not satisfactory, since it is impos-
sible to heal the cavity. I have practised the injection of antiseptic fluids
in some instances with benefit. In suitable cases drainage of the cavities
may be attempted, particularly if the patient is in fairly good condition.
For the fetid secretion turpentine may be given or terebene, and inhala-
tions used of carbolic acid or thymol. In extreme cases it is very difficult
to get rid of the offensive odor.
IV. BRONCHIAL ASTHMA.
Asthma is a term which has been applied to various conditions associ-
ated with dyspnoea — hence the names cardiac and renal asthma — but its
use should be limited to the affection known as bronchial or spasmodic
asthma.
Etiology. — All writers agree that there is in a majority of cases of
bronchial asthma a strong neurotic element. Many regard it as a neu-
rosis in which, according to one view, spasm of the bronchial muscles,
according to the other, turgescence of the mucosa, results from disturbed
innervation, pneumogastric or vaso-motor. Of the numerous theories the
following are the most important :
(1) That it is due to spasm of the bronchial muscles, a theory which
has perhaps the largest number of adherents. The original experiments
of C. J. B. Williams, upon which it is largely based, have not, however,
been confirmed of late years.
(2) That the attack is due to swelling of the bronchial mucous mem-
brane— fluctionary hyperaemia (Traube), vaso-motor turgescence (Weber),
diffuse hypera^mic swelling (Clark).
(3) That in many cases it is a special form of inflammation of the
smaller bronchioles — bronchiolitis exudativa (Curschmann). Other theo-
498 DISEASES OF THE RESPIRATORY SYSTEM.
ries which may be mentioned are that the attack depends on spasm of the
diaphragm or on reflex spasm of all the inspiratory muscles.
As already mentioned, the so-called hay fever is an affection which has
many resemblances to bronchial asthma, with which the attacks may alter-
nate. In the suddenness of onset and in many of their features these dis-
eases have the same origin and differ only in site, as suggested by Sir
Andrew Clark and now generally acknowledged by specialists. Making
due allowance for anatomical differences, if the structural changes occur-
ring in the nasal mucous membrane during an attack of hay fever were to
occur also in various parts of the bronchial mucosa, their presence there
would afford a complete and adequate explanation of the facts observed
during a paroxysm of bronchial asthma (Clark). With this statement I
fully agree, but the observations of Curschmann have directed attention
to a feature in asthma which has been neglected ; namely, that in a ma-
jority of the cases it is associated with an exudation, such as might be
supposed to come from a turgescent mucosa and which is of a very charac-
teristic and peculiar character. The hypersemia and swelling of the mu-
cosa and the extremely viscid, tenacious mucus explain well the hindrance
to inspiration and expiration and also the quality of the rdles.
Some general facts with reference to etiology may be mentioned. The
affection sometimes runs in families, particularly those Avith irritable and
unstable nervous systems. The attack may be associated with neuralgia
or, as Salter mentions, even alternate with epilepsy. Men are more fre-
quently affected than women. The disease often begins in childhood and
sometimes lasts until old age. One of its most striking peculiarities is the
bizarre and extraordinary variety of circumstances which at times induce
a paroxysm. Among these local conditions climate or atmosphere are
most important. A person may be free in the city and invariably suffer
from an attack when he goes into the country, or into one special part of
the country. Such cases are by no means uncommon. Breathing the air
of a particular room or a dusty atmosphere may bring on an attack.
Odors, particularly of flowers and of hay, or emanations from animals, as
the horse, dog, or cat, may at once cause an outbreak. Fright or violent
emotion of any sort may bring on a paroxysm. Uterine and ovarian
troubles were formerly thought to induce attacks and may do so in rare
instances. Diet, too, has an important influence, and in persons subject to
the disease severe paroxysms may be induced by overloading the stomach,
or by taking certain articles of food. Chronic cases, in which the attacks
recur year after year, gradually become associated with emphysema, and
every fresh " cold " induces a paroxysm. And lastly, many cases of bron-
chial asthma are associated with affections of the nose, particularly with
hypertrophic rhinitis and nasal polypi. According to some specialists of
large experience, all cases of bronchial asthma have some affection of the
upper air-passages, but I am convinced from personal observation that
this is erroneous. Still physicians must acknowledge the debt which we
BRONCHIAL ASTHMA. • 499
owe to Voltolini, Hack, Daly, Roe, and others who have shown the close
connection which exists between affections of the nose and many cases of
bronchial asthma.
Briefly stated then, bronchial asthma is a neurotic affection, character-
ized by hyperaemia and turgescence of the mucosa of the smaller bronchial
tubes and a peculiar exudate of mucin. The attacks may be due to direct
irritation of the bronchial mucosa or may be induced reflexly, by irritation
of the nasal mucosa, and indirectly, too, by reflex influences, from stom-
ach, intestines, or genital organs.
Symptoms. — Premonitory sensations precede some attacks, such as
chilly feeling, a sense of tightness in the chest, flatulence, passage of a
large quantity of urine, or great depression of spirits. Nocturnal attacks
are common. After a few hours' sleep, the patient is aroused with a dis-
tressing sense of want of breath and a feeling of great oppression in the
chest. Soon the respiratory efforts become violent, all the accessory mus-
cles are brought into play, and in a few minutes the patient is in a par-
oxysm of the most intense dyspnoea. The face is pale, the expression
anxious, speech is impossible, and in spite of the most strenuous inspira-
tory efforts very little air enters the lungs. Expiration is prolonged and
also wheezy. The number of respirations, however, is not much increased.
The asthmatic fit may last from a few minutes to several hours. When
severe, the signs of defective aeration soon appear, the face becomes be-
dewed with sweat, the pulse is small and quick, the extremities get cold,
and just as the patient seems to be at his vv^orst, the breathing begins to
get easier, and often with a paroxysm of coughing relief is obtained and
he sinks exhausted to sleep. The relief may be but temporary and a sec-
ond attack may soon come on. In a majority of the cases even in the
intervals between the asthmatic fits the respiration is somewhat embar-
rassed. The cough is at first very tight and dry and the expectoration is
expelled with the greatest difficulty.
The physical signs during an attack are very characteristic. On in-
spection the thorax looks enlarged, barrel-shaped, and is fixed, the amount
of expansion being altogether disproportionate to the intensity of the in-
spiratory movements. The diaphragm is lowered and moves but slightly.
Inspiration is short and quick, expiration prolonged. Percussion may not
reveal any special difference, but there is sometimes marked hjrperreso-
nance, particularly in cases which have had repeated attacks.
On auscultation, with inspiration and expiration, there are innumer-
able sibilant and sonorous rales of all varieties, piping and high-pitched,
low-pitched and grave. Later in the attack there are moist rales.
The sputum in bronchial asthrffa is quite distinctive, unlike that which
occurs in any other affection. Early in the attack it is brought up with
great difficulty and is in the form of rounded gelatinous masses, the so-
called "/>er/e,?" of Laennec. Though ball-like, they can be unfolded and
really represent moulds in mucus of the smaller tubes. The entire expcc-
500 DISEASES OF THE RESPIRATORY SYSTEM.
toration may be made up of these somewhat translucent-looking pellets,
floating in a small quantity of thin mucus. Some of them are opaque.
Often with the naked eye a twisted spiral character can be seen, particu-
larly if the sputum is spread on a glass with a black background. Micro-
scopically, many of these pellets have a spiral structure, which renders
them among the most remarkable bodies met with in sputum. It is not
a little curious that they should have been practically overlooked until
described a few years ago by Curschmann. Under the microscope the
spirals are of two forms. In one there is simply a twisted, spirally ar-
ranged mucin, in which are entangled cells, derived probably from the
smaller bronchi and alveoli, often in all stages of fatty degeneration.
The twist may be loose or tight. The second form is much more peculiar.
In the centre of a tightly coiled skein of mucin fibrils with a few scattered
cells is a filament of extraordinary clearness and translucency, probably
composed of transformed mucin. As Curschmann suggests, these spirals
are doubtless formed in the finer bronchioles and constitute the product
of an acute bronchiolitis. It is difficult to explain their spiral nature. I
do not know of any observations upon the course of the currents produced
by the ciliated epithelium in the bronchi, but it is quite possible that their
action may be rotatory, in which case, particularly when combined w4th
spasm of the bronchial muscles, it is possible to conceive that the mucus
formed in the tube might be compelled to assume a spiral form. Within
two or three days the sputum changes entirely in character ; it becomes
muco-purulent and Curschmann's spirals are no longer to be found. They
occur in all instances of true bronchial asthma in the early period of the
attack. There are, in addition, in many cases, the pointed, octahedral
crystals described by Leyden and sometimes called asthma crystals. They
are identical with the crystals found in the semen and in the blood in
leukaemia. At one time they were supposed, by their irritating character,
to induce the paroxysms.
The course of the disease is very variable. In severe attacks the par-
oxysms recur for three or four nights or even more, and in the intervals
and during the day there may be wheezing and cough. Early in the disease
the patient may be free in the morning, without cough or much distress,
and the attacks may appear at first to be of a purely nervous character.
In the long-standing cases emphysema almost invariably develops, and
while the pure asthmatic fits diminish in frequency the chronic bronchitis
and shortness of breath become aggravated.
We have no knowledge of the morbid anatomy of true asthma. Death
during the attack is unknown. In long-standing cases the lesions are
those of chronic bronchitis and emphysema.
Treatment. — The asthmatic attack usually demands immediate and
prompt treatment, and remedies should be administered which experience
has shown are capable of relieving the condition of the bronchial mucosa.
A few whiffs of chloroform will produce prompt though temporary relaxa-
FIBRINOUS BRONCHITIS. 501
tion. In a child with very severe attacks, resisting all the usual remedies,
the treatment by chloroform gave immediate and finally permanent relief.
Pei'les of nitrite of amyl may be broken on the handkerchief or from two
to five drops of the solution may be placed upon cotton-wool and inhaled.
Strong stimulants given hot or a dose of spirits of chloroform in hot
whisky will sometimes induce relaxation. More permanent relief is given
by the hypodermic injection of morphia or of morphia and cocaine com-
bined. In obstinate and repeatedly recurring attacks this has proved a
very satisfactory plan. The sedative antispasmodics, such as belladonna,
henbane, stramonium, and lobelia, may be given in solution or used
in the form of cigarettes. Nearly all the popular remedies either in this
form or in pastilles contain some of the plant of the order solanacecB^ with
nitrate or chlorate of potash. Excellent cigarettes are now manufactured
and asthmatics try various sorts, since one form benefits one patient,
another form another patient. Nitre paper made with a strong solution
of nitrate of potash is very serviceable. Filling a room with the fumes
of this paper prior to retiring will sometimes ward off a nocturnal attack.
I have known several patients to whom tobacco smoke inhaled was quite
as potent as the prepared cigarettes.
The use of compressed air in the pneumatic cabinet is very beneficial ;
oxygen inhalations may be also tried. In preventing the recurrence of
the attacks there is no remedy so useful as iodide of potassium, which
sometimes acts like a specific. From ten to twenty grains three times a
day is usually sufficient.
Particular attention should be paid to the diet of asthmatic patients.
A rule which experience generally compels them to make is to take the
heavy meals in the early part of the day and not retire to bed before gas-
tric digestion is completed. As the attacks are often induced by flatu-
lency, the carbohydrates should not be allowed. Coffee is a more suitable
drink than tea. In respect to climate it is very difficult to lay down rules
for asthmatics. The patients are often much better in the city than in
the country. The high and dry altitudes are certainly more beneficial
than the sea-shore ; but in protracted cases, with emphysema as a secondary
complication, the rarefied air of high altitudes is not advantageous. In
young persons I have known a residence for six months in Florida or
southern California to be followed by prolonged freedom from attacks.
V. FIBRINOUS BRONCHITIS.
An acute or chronic affection, characterized by the formation in cer-
tain of the bronchial tubes of fibrinous casts, which are expelled in parox-
ysms of dyspnoja and cough.
In several diseases fibrinous moulds of the bronchi are formed, as in
diphtheria and croup (with extension into the trachea and bronchi), in
502 DISEASES OF THE RESPIRATORY SYSTEM.
pneumonia, and occasionally in phthisis — conditions which, however, have
nothing to do with true fibrinous bronchitis. These casts are not to be
confounded with the blood-casts which occur occasionally in haemoptysis.
!Etiology. — Nothing is known of its causation. It occurs more fre-
quently in males. It is met with at all periods of life, but is more common
between the ages of twenty and forty. It has been known to attack several
members of the same family. Cases have been described occurring together
as if due to some endemic influence (Pichini). The cases are rare, particu-
larly in hospital practice. . The attacks occur most commonly in the
spring months. An association with tuberculosis has been frequently noted.
Model, in an article from Baumler's clinic, states that tuberculosis was
present in ten of twenty-one post-mortems. It has been met with also in
connection with skin-diseases, such as pemphigus, impetigo, and herpes.
The attacks appeared to be related in some cases to the menstrual period.
Several instances have been described with heart-disease, but it seems
probable that in all these conditions the connection was not causal.
Symptoms. — Acute cases are rare. They may set in with high
fevers, rigors, severe paroxysms of cough, and perhaps with haemoptysis.
The clinical picture resembles acute bronchitis, and only the expulsion
of the membranous casts gives the characteristic features to the case. It
is much more serious than the chronic form and fatal termination is not
uncommon. N. S. Davis has reported two fatal cases. In some of the
acute cases there has been affection of the tonsils, and it is possible that
the disease may have been truly diphtheritic in character and due to ex-
tension of the membrane into the trachea and bronchi. The casts in these
cases are not only more extensive, but they also do not present the lami-
nated structure characteristic of true plastic bronchitis.
A patient may have a single attack without any recurrence, but in the
chronic form the attacks come on at varying intervals and the disease may
last for ten or even twenty years. Instances are on. record in which the
paroxysms have occurred at definite intervals for many months. The at-
tacks may recur weekly or a period of a year or more may intervene. The
onset is marked by bronchitic symptoms, not necessarily with fever. The
cough becomes distressing and paroxysmal in character ; the sputa may be
blood-stained and the patient brings up rounded, ball-like masses, which,
when disentangled, are found to be moulds of bronchi ; the haemorrhage
may be profuse. In one of the two cases which I have seen it invariably
accompanied the attack, and the whitish dendritic casts of the tubes were
always entangled in the blood and clots. Urgent dyspnoea and cyanosis
may be present in severe attacks. The physical signs are those of a severe
bronchitis. It may occasionally be possible to determine the weakened or
suppressed breath sounds in the affected territory and there may be deficient
expansion or even retraction of the chest wall in a corresponding area, but
this is in reality very difficult, and twice prior to the expulsion of the
casts I failed to determine by physical examination the affected region.
CIRCULATORY DISTURBANCES IN THE LUNGS. 503
As mentioned, the casts are usually rolled up and mixed with mucus or
blood. When unravelled in water they present a complete mould of a
secondary or tertiary bronchus with its ramifications. The size of the cast
may vary with different attacks, but, as has often been noticed, the form
and size may be identical at each attack as if precisely the same bronchial
area was involved each time. The casts are hollow, laminated, the size of
the lumen varying with the number and thickness of the laminae. Some-
times they are almost solid. Transverse sections show a beautiful concen-
tric arrangement. The fibrin appears in places to retain its fibrillary
structure ; in others, as in diphtheritic membrane, it has undergone the
hyaline transformation. Leucocytes are imbedded in the meshes. In the
centre, particularly in the smaller casts, it is not uncommon to see alveolar
epithelium with numerous carbon j)articles. Leyden's crystals are some-
times found and occasionally Curschmann's spirals.
The pathology of the disease is obscure. The membrane is identical
with that to which the term croupous is applied, and the obscurity relates
not so much to the mechanism of the production, which is probably the
same as in other mucous surfaces, as to the curious limitation of the affec-
tion to certain bronchial territories and the remarkable recurrence at stated
or irregular intervals throughout a period of many years.
In the acute cases the treatment should be that of ordinary acute bron-
chitis. We know of nothing which can prevent the recurrence of the
attacks in the chronic form. In the uncomplicated cases there is rarely
any danger during the paroxysm, even though the symptoms may be most
distressing and the dyspnoea and cough very severe. Inhalations of ether,
steam, or atomized lime-water aid in the separation of the membranes.
Pilocarpine might be useful, as in some instances it increases the bronchial
secretion. The employment of emetics may be necessary, and in some
cases they are effective in promoting the removal of the casts.
lY. DISEASES OF THE LUT^GS.
I. CIRCULATORY DISTURBANCES IN THE LUNGS.
Congestion.— There are two forms of congestion of the lungs— active
and passive.
(1) Active Congestion of the Lungs.— M.\\c\i doubt and confusion still
exist on this subject. French writers, following Woillez, regard it as an
independent primary affection [maladie de Woillez), and in their diction-
aries and text-books allot much space to it. English and American
authors more correctly regard it as a symptomatic affection. Active flux-
ion to the lungs occurs with increased action of the heart, and when very
hot ail or irritating substances are inhaled. In diseases which interfere
504: DISEASES OF THE RESPIRATORY SYSTEM.
locally with the circulation the capillaries in the adjacent unaffected por-
tions may be greatly distended. The importance, however, of this collat-
eral fluxion, as it is called, is probably exaggerated. In a whole series of
pulmonary affections there is this associated congestion — in pneumonia,
bronchitis, pleurisy, and tuberculosis.
The symptoms of active congestion of the lungs are by no means defi-
nite. The description given by Woillez and by other French writers is
of an affection which is difficult to recognize from anomalous or larval
forms of pneumonia. The chief symptoms described are initial chill, pain
in the side, dyspnoea, moderate cough, and temperature from 101° to 103°.
The physical signs are defective resonance, feeble breathing, sometimes
bronchial in character, and fine rales. A majority of clinical physicians
would undoubtedly class such cases under inflammation of the lung. In
many epidemics the abnormal and larval forms are specially prevalent.
This is no doubt the condition to which Porcher, of Charlestown, called
attention a short time ago as a " hitherto undescribed affection of the
lungs."
The occurrence of an intense and rapidly fatal congestion of the lung,
following extreme heat or cold or sometimes violent exertion, is recognized
by some authors. Kenforth, the oarsman, is said to have died from this
cause during the race at Halifax. Leuf has described cases in which, in
association with drunkenness, exposure, and cold, death occurred suddenly,
or within twenty-four hours, and the only lesion found has been an ex-
treme, almost haemorrhagic, congestion of the lungs. It is by no means
certain that in these cases death really occurs from pulmonary congestion
in the absence of specific statements with reference to the coronary ar-
teries. Several times in sudden death from disease of these vessels I have
seen great engorgement of the lungs though not the extreme grade men-
tioned by Leuf. I have no personal knowledge of cases such as he
describes.
(2) Passive Congestion. — Two forms of this may be recognized, the
mechanical and the hypostatic.
{a) IMechanical congestion occurs whenever there is an obstacle to the
return of the blood to the heart. It is a common event in many affections
of the left heart. The lungs are voluminous, russet brown in color, cut-
ting and tearing with great resistance. On section they show at first a
brownish-red tinge, and then the cut surface, exposed to the air, becomes
rapidly of a vivid red color from oxidation of the abundant haemoglobin.
Tliis is the condition known as brown induration of the lung. Hi^tologi-
cally it is characterized by (a) great distention of the alveolar capillaries ;
(j8) increase in the connective-tissue elements of the lung ; (y) the pres-
ence in the alveolar walls of many cells containing altered blood-pigment ;
(8) in the alveoli numerous epithelial cells containing blood-pigment in
all stages of alteration, which are also found in great numbers in the
sputum.
CIRCULATORY DISTURBANCES IN THE LUNUS. 505
It occasionally happens that this mechanical hyperaimia of the lung
results from pressure of tumors. So long as compensation is maintained
the mechanical congestion of the lung in heart-disease does not produce
any symptoms, but with enfeebled heart action the engorgement becomes
marked and there are dyspnoea, cough, and expectoration, with the char-
acteristic alveolar cells.
(b) Hypostatic congestion. In fevers and adynamic states generally it
is very common to find the bases of the lungs deeply congested, a condi-
tion induced partly by the effect of gravity, the patient lying recumbent
in one posture for a long time, but chiefly by weakened heart action.
That it is not an effect of gravity alone is shown by the fact that a healthy
person may remain in bed an indefinite time without its occurrence. The
term hypostatic congestion is applied to it. The posterior parts of the
lung are dark in color and engorged with blood and serum ; in some in-
stances to such a degree that the alveoli no longer contain air and portions
of the lung sink in water. The term splenization and hypostatic pneu-
monia have been given to these advanced grades. It is a common affec-
tion in protracted cases of typhoid fever and in long debilitating illnesses.
In ascites, meteorism, and abdominal tumors the bases of the lungs may
be compressed and congested. In this connection must be mentioned the
form of passive congestion met with in injury to, and organic disease of,
the brain. In cerebral apoplexy the bases of the lungs are deeply en-
gorged, not quite airless^ but heavy, and on section drip with blood and
serum. I have twice seen this condition in an extreme grade throughout
the lungs in death from morphia poisoning. In some instances the lung
tissue has a blackish, gelatinous, infiltrated appearance, almost like diffuse
pulmonary apoplexy. Occasionally this congestion is most marked in, and
even confined to, the hemiplegic side. In prolonged coma the hypostatic
congestion may be associated with patches of consolidation, due to the
aspiration of portions of food into the air-passages.
The symptoms of hypostatic congestion are not at all characteristic,
and the condition has to be sought for by careful examination of the bases
of the lungs, when slight dulness, feeble, sometimes blowing, breathing
and liquid rales can be detected.
The treatment of congestion of the lungs is usually that of the condi-
tion with which it is associated. In the intense pulmonary engorgement,
which may possibly occur primarily, and which is met with in heart-disease
and emphysema, free bleeding should be practised. From twenty to thirty
ounces of blood should be taken from the arm, and if the blood does not
flow freely and the condition of the patient is desperate, aspiration of the
right auricle may be performed.
(Edema. — In all forms of intense congestion of the lungs there is a
transudation of serum from the engorged capillaries chiefly into the air-
cells, but also into the alveolar walls. Not only is it very frequent in con-
gestion, but also with inflammation, with new growths, infarcts, and tuber-
83
506 DISEASES OF THE RESPIRATORY SYSTEM.
cles. AVlien limited to the neighborhood of an affected part, the name
collateral oedema is sometimes applied to it. General oedema occurs under
conditions very similar to those met with in congestion. It is very often,
no doubt, a terminal event, occurring with the death agony. It is seen in
typical form in the cachexias, in death from anaemia, also in chronic
Bright's disease, disease of the heart, and cerebral affections.
The oedematous lung is heavy, looks watery, pits on pressure, and from
the cut surface a large quantity of clear and, in cases of congestion, bloody
serum flows freely ; the tissue may even have a gelatinous, infiltrated ap-
peapance. The condition is much more common at the bases, but it may
exist throughout the entire lung. The pathology of pulmonary oedema is
not always clear. Two factors usually prevail in extreme cases — increased
tension within the pulmonary system and a diluted blood plasma. The
increased tension alone is not capable of producing it. The experiments
of Welch seem to indicate that the essential factor lies in a disproportion-
ate weakness of the left ventricle, so that the blood accumulates in the
lung capillaries until transudation occurs, a view which satisfactorily ex-
plains certain cases, particularly the terminal oedemas.
The symptoms of oedema of the lungs are often only an aggravation of
those already existing, and are due to the primary disease, whether car-
diac, renal, or general. There are usually increasing dyspnoea and cough,
and on examination there may be defective resonance and large liquid rales
at the bases. There are cases in which the oedema comes on with great
suddenness, and in chronic Bright's disease it may prove rapidly fatal.
In the cases of so-called inflammatory oedema fever is always present,
and often signs, more or less marked, of pneumonia.
The treatment of oedema of the lung is practically that of the condi-
tions with which it is associated. In the acute cases active catharsis, and,
if there is cyanosis, free venesection should be resorted to.
Pulmonary HsBinorrhage. — This occurs in two forms — hronclio-pid-
monary hmmorrhage^ sometimes called bronchorrhagia, in which the blood
is poured out into the bronchi and is expectorated, and inilmonary apo-
plexy or pneumorrhagia, in which the haemorrhage takes place into the
air-cells and the lung tissue.
1. Bronclio-pulmonary Hmmorrliage ; Hwmoptysis. — Spitting of blood,
to which the term haemoptysis should be restricted, results from a variety
of conditions, among which the following are the most important : {a) In
young healthy persons haemoptysis may occur without warning, and after
continuing for a few days disappear and leave no ill traces. There may
be at the time of the attack no physical signs indicating pulmonary disease.
In such cases good health may be preserved for years and no further
trouble occur. These cases are not very uncommon. In "Ware's impor-
tant contribution to this subject,* of '^^(S cases of haemoptysis noted in
* On Haemoptysis as a Symptom, by John Ware, M. D.
CmCULATORY DISTURBANCES IN TIIP] LUNGS. 507
private practice 62 recovered and pulmonary disease did not subsequently
develop in them. I know three professional men who had haemoptysis as
students, and who now, at periods of from fifteen to eighteen years subse-
quently, remain in perfect health, (b) IIa3moptysis in pulmonary tubercu-
losis. So frequently are these conditions associated that in the lay mind sj)it-
ting of blood and consumption are almost synonymous. The Ilippocratic
aphorism, " From a spitting of blood there is a spitting of pus," is repeated
throughout the literature of more than twenty centuries. It occurs either
early in the disease, before there are any obvious physical signs, or after the
development of Avell-marked local lesions. Unquestionably in a majority of
the cases in which subsequent to haemoptysis phthisis occurs tubercles were
already present in the lung. The haemorrhage is bronchial and associated
with a limited focus of disease. When the pulmonary lesion is more ad-
vanced the haemoptysis results either from erosion of a branch of the
pulmonary artery or from rupture of an aneurismal dilatation of the same.
(c) In connection with certain diseases of the lung, as pneumonia (in the
initial stage) and cancer, occasionally in gangrene, abscess, and bronchiec-
tasis, hemoptysis occurs, (d) Haemoptysis is met with in many heart
aifections, particularly mitral lesions. It may be profuse and recur at
intervals for years, (e) In ulcerative affections of the larynx, trachea, or
bronchi. Sometimes the haemorrhage is profuse and rapidly fatal, as
when an ulcer erodes a large branch of the pulmonary artery, an accident
which I have known to happen in a case of chronic bronchitis with em-
physema. (/) Aneurism is an occasional cause of haemoptysis. It may
be sudden and rapidly fatal when the sac bursts into the air-passages.
Slight bleeding may continue for weeks or even longer, due to pressure on
the mucous membrane, erosion of the lung, or in some cases the sac
" weeps '' through the exposed laminae of fibrin, (g) Vicarious haemor-
rhage, which occurs in rare instances in cases of interrupted menstruation.
The instances are well authenticated. Flint mentions a case which he
had had under observation for four years, and Hippocrates refers to it in
the aphorism, " Haemoptysis in a woman is removed by an eruption of the
menses." Periodical haemoptysis has also been met with after the removal
of both ovaries. Even fatal haemorrhage has occurred from the lung during
menstruation when no lesion was found to account for it. (h) There is a
form of recurring haemoptysis in arthritic subjects to which Sir Andrew
Clark has called special attention and which also is described by French
writers. The cases occur in persons over fifty years of age who usually
present signs of the arthritic diathesis. It rarely leads to fatal issue and
subsides without inducing pulmonary changes. (?*) Haemoptysis recurs
sometimes in malignant fevers and in purpura haemorrhagica. Lastly, there
is endemic haemoptysis, due to the presence of the Distoma Ringeri in the
bronchial tubes, an affection which is confined to parts of China and Japan.
Symptoms.— Haemoptysis sets in as a rule suddenly. Often with-
out warning the patient experiences a warm, saltish taste as the mouth
508 DISEASES OF THE RESPIRATORY SYSTEM.
fills with blood. Coughing is usually induced. There may be only
an ounce or so brought up before the bleeding stops, or the bleeding
may continue for days, the patient bringing up small quantities. In other
instances, particularly when a large vessel is eroded or an aneurism bursts,
the amount is large, and the patient after a few attempts at coughing
shows signs of suffocation and death is produced by inundation of the
bronchial system. Fatal haemorrhage may even occur into a large cavity
in a patient debilitated by phthisis without the production of haemoptysis.
I dissected a case of this kind at the Philadelphia Hospital. The blood
from the lungs generally has characters which render it readily distin-
guishable from the blood which is vomited. It is alkaline in reaction,
frothy, and mixed with mucus, and when coagulation occurs air-bubbles are
present in the clot. Blood-moulds of the smaller bronchi are sometimes
seen. Patients can usually tell whether the blood has been brought up by
coughing or by vomiting, and in a majority of cases the history gives im-
portant indications. In paroxysmal haemoptysis connected with menstrual
disturbances the practitioner should see that the blood is actually coughed
up, since deception may be practised. Naturally, the patient is at first
alarmed at the occurrence of bleeding, but, unless very profuse, as when
due to rupture of an aortic aneurism in a pulmonary cavity, the danger is
rarely immediate. The attacks, however, are apt to recur for a few days
and the sputa may remain blood-tinged for a longer period. In the great
majority of cases the haemorrhage ceases spontaneously. It should be re-
membered that some of the blood may be swallowed and produce vomit-
ing, and, after a day or two, the stools may be dark in color. It is not
well during an attack of haemoptysis to examine the chest. It was for-
merly thought that hsemorrhage exercised a prejudicial effect and excited
inflammation of the lungs, but this is not often the case.
(2) Pulmonary Apoplexy ; Hcemorrhagic Infarct. — In this condition
the blood is effused into the air-cells and interstitial tissue. It is rarely
indeed diffuse, breaking the parenchyma as the brain tissue is broken in
cerebral apoplexy. Sometimes, in disease of the brain, in septic condi-
tions, and in the malignant forms of fevers, the lung tissue is uniformly
infiltrated with blood and has, on section, a black, gelatinous appearance.
As a rule, the haemorrhage is limited and results from the blocking of
a branch of the pulmonary artery either by a thrombus or an embolus.
The condition is most common in chronic heart-disease. Although the
pulmonary arteries are terminal ones, blocking is not always followed by
infarction ; partly because the wide capillaries furnish sufficient anasto-
mosis, and partly because the bronchial vessels may keep up the circula-
tion. The infarctions are chiefly at the periphery of the lung, usually
wedge-shaped, with the base of the wedge toward the surface. When re-
cent, they are dark in color, hard and firm, and look on section like an
ordinary blood-clot. Gradual changes go on, and the color becomes a
reddish brown. The pleura over an infarct is usually inflamed. A mi-
CIRCULATORY DISTURBANCES IN THE LUNGS. 509
croscopical section shows the air-cells to be distended with red blood-cor-
puscles, which may also be in the alveolar walls. The infarcts are usually
multiple and vary in size from a walnut to an orange. Very large ones
may involve the greater part of a lobe. In the artery passing to the
affected territory a thrombus or an embolus is found. The globular
thrombi, formed in the right auricular appendix, play an important part
in the production of haemorrhagic infarction. In many cases the source
of the embolus cannot be discovered, and the infarct may have resulted
from thrombosis in the pulmonary artery, but, as before mentioned, it is
not infrequent to find total obstruction of a large branch of a pulmonary
artery without haemorrhage into the corresponding lung area. The fur-
ther history of an infarction is variable. It is possible that in some in-
stances the circulation is re-established and the blood removed. More
commonly, if the patient lives, the usual changes go on in the extravasated
blood and ultimately a pigmented, puckered, fibroid patch results. Slough-
ing may occur with the formation of a cavity. Occasionally gangrene
results. In a case at the L^niversity Hospital, Philadelphia, a gangrenous
infarct ruptured and produced fatal pneumothorax.
The symptoms of pulmonary apoplexy are by no means definite. The
condition may be suspected in chronic heart-disease when haemoptysis
occurs, particularly in mitral stenosis, but the bleeding may be due to the
extreme engorgement. When the infarcts are very large, and particularly
in the lower lobe, in which they most commonl}- occur, there may be signs
of consolidation with blowing breathing.
Treatment of Pulmonary Haemorrhage. — In the treatment
of haemoptysis it is important to remember the condition of the pulmo-
nary circulation and the nature of the lesions associated with the haemor-
rhage.
The pressure within the pulmonary artery is considerably less than that
in the aortic system. We have as yet very imperfect knowledge of the
circumstances which influence the lesser circulation in man. Researches,
particularly those of Bradford, indicate that the system is under vaso-
motor control, but our knowledge of the mutual relations of pressure m
the aorta and in the pulmonary artery, under varying conditions, is still
very imperfect. Experiments with drugs seem to show that there may be
an influence on systemic blood-pressure without any on the pulmonary,
and the pressure in the one may rise while it falls in the other, or it may
rise and fall in both together. In Andrew's Harveian Oration these rela-
tions are thoroughly described, and a statement is made, based on Brad-
ford's experiments, as to the action on the pulmonary blood-pressure of
many of tlie drugs employed in haemoptysis. Thus ergot, the remedy
perhaps most commonly used, causes a distinct rise in the pulmonary
blood -pressure, while aconite produces a definite fall.
The anatomical condition in haemoptysis is either hyperaemia of the
bronchial mucosa (or of the lung tissue) or a perforated artery. In the
510 DISEASES OF THE RESPIRATORY SYSTEM.'
latter case the patient often passes rapidly beyond treatment, though there
are instances of the most profuse haemorrhage which must have come from
a perforated artery or a ruptured aneurism in which recovery has occurred.
Practically, for treatment, we should separate these cases, as the remedies
which would be applicable in a case of congested and bleeding mucosa
would be as much out of place in a case of haemorrhage from ruptured
aneurism as in a cut radial artery. When the blood is brought up in
quantities — in mouthfuls at a time — it is almost certain either that an
aneurism has ruptured or a vessel has been eroded. In the instances in
which the sputa are blood-tinged or when the blood is in smaller quanti-
ties, bleeding comes by diapedesis from hyperaemic vessels. In such cases
the haemorrhage may be beneficial in relieving the congested blood-vessels.
The indications are to reduce the frequency of the heart-beats and to
lower the blood-pressure. By far the most important measure is absolute
quiet of body, such as can only be secured by rest in bed and seclusion.
In the majority of cases of mild haemoptysis this is sufficient. Even
when the patient insists upon going about, the bleeding may stop spon-
taneously. The diet should be light and unstimulating. Alcohol should
not be used. The patient may, if he wishes, have ice to suck. Small
doses of aromatic sulphuric acid may be given, but unless the bleeding
is protracted styptic and astringent medicines are not indicated. For
cough, which is always present and disturbing, opium should be freely
given, and is of all medicines most serviceable in haemoptysis. Digitalis
should not be used, as it raises the blood-pressure in the pulmonary artery.
Aconite, as it lowers the pressure, may be used when there is much vascu-
lar excitement. Ergot, tannic acid, and lead, which are so much em-
ployed, have, I believe, little or no influence in haemoptysis. Ergot, accord-
ing to Bradford, produces distinct rise in the pulmonary blood-pressure.
One of the most satisfactory means of lowering the blood-pressure is purga-
tion, and when the bleeding is protracted salts may be freely given. In
profuse haemoptysis, such as comes from erosion of an artery or the rupt-
ure of an aneurism, a fatal result is common, and yet post-mortem evi-
dence shows that thrombosis may occur with healing in a rupture of con-
siderable size. The fainting induced by the loss of blood is probably the
most efficient means of promoting thrombosis, and it was on this principle
that formerly patients were bled from the arm, or from both arms, as in
the case of Laurence Sterne. Ligatures, or Esmarch's bandages, placed
around the legs may serve temporarily to check the bleeding. The ice-
bag on the sternum is of doubtful utility. In a protracted case Cayley in-
duced pneumothorax, but without effect.
Briefly, then, we may say that cases of haemorrhage from rupture of
aneurism or erosion of a blood-vessel usually prove fatal. The fainting
induced by the loss of blood is beneficial, and, if the patient can be kept
alive for twenty-four hours, a thrombus of sufficient strength to prevent
further bleeding may form. The chief danger is the inundation of the
PNEUMONIA. 511
bronchial system with the blood, so that while the haemorrhage is profuse
the cough should be encouraged. Opium should not then be used, and
stimulants should be given with caution.
In the other group, in which the haemorrhage comes from a congested
area and is limited, the patient gets well if kept absolutely quiet, and
fatal hsemorrhage probably never occurs from tliis source. Kest, reduc-
tion of the blood-pressure by minimum diet, purging, if necessary, and the
administration of opium to allay the cough are the main indications.
II. PNEUMONIA
{Lobar, Croupous, or Fibrinous Pneumonia; Pneumonitis ; Lung Fever).
Definition. — An infectious disease characterized by inflammation of
the lungs and constitutional disturbance of varying intensity. The fever
terminates abruptly by crisis. Secondary infective processes are common
An organism, the diplococcus pneumonice, is invariably found in the dis-
eased lung.
Etiology. — Pneumonia is one of the most wide-spread of acute
diseases. Hospital statistics show that the ratio to other admissions is in
the proportion of twenty to thirty per thousand.
It prevails at all ages Children are quite as susceptible to it as adults,
and it is the special enemy of old age. Males are more frequently affected
than females. Dwellers in cities and persons whose occupations are as-
sociated with exposure, hardship, and cold are most liable to the dis-
ease. Contrary to the general rule in infectious diseases, newcomers and
immigrants seem less susceptible than the native inhabitants. Debilitat-
ing causes of all sorts render individuals more susceptible. Alcoholism
is perhaps the most potent predisposing factor. Persons weakened by
disease are especially prone to it ; thus we find many cases in connection
with chronic Bright's disease, diabetes, the chronic affections of the nerv-
ous system, and protracted fevers. One important predisposing cause is a
previous attack. No acute disease recurs with such frequency. Instances
are on record of individuals who have had ten or more attacks.
Climate does not appear to have much influence. The disease pre-
vails equally in cold and in hot countries, but it is stated that on this
continent it is more prevalent in the Southern than in the Northern States.
More important is the influence of season. Statistics everywhere show
that more persons are attacked from December to May than in the sum-
mer and autumn. Seitz's large statistics of 5,005 cases in Munich give
32 per cent in winter, 30-8 per cent in spring, 15-3 per cent in summer,
and 15-7 per cent in autumn. Bell's statistics of the Montreal General
lIosj:)ital show practically tlie same distribution, but it is worth noting
that during January, the coldest month of the year, in which the mean
temperature for ten years was 13*75° F., the percentage was compara-
512 DISEASES OF THE RESPIRATORY SYSTEM.
tively low. January, however, is a month with very slight variations in
temperature, and it seems that the sudden changes characteristic of
March, April, and May are the important climatic factors which predis-
pose to pneumonia.
Of other factors, cold has been thought to be one of the most im-
portant, and for years was regarded as the efficient cause of the disease.
Undoubtedly the disease sometimes promptly follows a sudden chilling or
wetting, but in a large majority of cases no such history can be obtained.
Pneumonia follows traumatism with great frequency, more particu-
larly injury of the chest. Litten has called special attention to this so-
called co7itusions-pneiomonia.
A change of opinion has of late taken place as to the nature of pneu-
monia, which is now almost universally regarded as a specific infectious
disease, depending upon a micro-organism. Among general circum-
stances favoring this view, is the occurrence of pneumonia in epidemic
form^ a fact recognized by Laennec and by Grisolle. Many house
epidemics have been described within the past twenty years. On sev-
eral occasions I have known two, three, and even four persons admitted
to hospital from the same house. In 1887, I saw, with Graham, of To-
ronto, a local outbreak in which three members of a family were consecu-
tively attacked with the most malignant pneumonia. There are instances
on record in which as many as ten residents in one house have been at-
tacked. Of late years many epidemics in towns have been reported.
Still more striking are the epidemics which have been described in prisons
and garrisons, of which one of the most remarkable is that reported by
W. B. Rodman, of Frankfort, Kentucky. In one year there occurred in
a prison population of 735 > 118 cases, with 25 deaths. The prison was
much overcrowded at the time. Similar epidemics have been described in
Europe. At the penitentiary at Amberg, from the 1st of January to the
1st of June, there were 161 cases of pneumonia with a mortality of over
twenty-eight per cent.
The diplococcus pneumonim of Fraenkel is the most constant organism
in lobar pneumonia and is now believed by many competent authorities
to be the specific agent of the disease. It is identical with the micrococ-
cus which Pasteur and Sternberg found in the saliva of certain individu-
als and which produces septicaemia in the rabbit. It occurs occasionally
in the nose, the larynx, and the Eustachian tube. According to Netter's ob-
servations, it is present in the buccal secretion in twenty per cent of healthy
persons. It persists for months or even years in the saliva of persons
who have had pneumonia. The researches of Fraenkel, AVeichselbaum,
Oamaleia, and others show that it is by far the most constant organism in
pneumoniji and that it occurs in the secondary processes of the disease,
such as pleurisy, endocarditis, pericarditis, and meningitis. In ten cases
recently examined at the pathological laboratory of the Johns Hopkins
Hospital by my colleague Welch, this organism was present in all ; in
PNEUMONIA. 513
six as pure cultures in the lung, in four together with pus organisms.
In the sputum it may he demonstrated by treating tlie ordinary cover-
glass preparations witli glacial acetic acid and then, without washing oft* the
acid, dropping on aniline oil and gentian-violet, which is to be poured oil*
and renewed two or three times. The organism is seen to be a somewhat
elliptical lance-shaped coccus occurring in pairs, hence the term diplococ-
cus. It is usually encapsulated.
According to the dominant view, pneumonia is an infective disease
caused by this diplococcus, which has its seat of election in and produces
its chief effects on the lung, and which can, under favoring circumstances,
invade other parts of the body — the pleura, meninges, and endocardium
This microbe may possibly attack these parts without the intervention of
inflammation of the lung, as it has been found in meningitis and pleurisy
independent of pneumonia. It is a wide-spread organism, at times pres-
ent, as before stated, in the buccal secretions of healthy persons. It is not
improbable that the various predisposing causes, such as cold, exhaustion,
and debility, lower the vitality and render the individual susceptible,
thus changing the character of the tissue-soil so that the virus can grow
and produce its specific effects.
On this view, pneumonia may be regarded as a local disease, produced
by micro-organisms which induce, as in other local diseases, such as ery-
sipelas and diphtheria, constitutional disturbance of varying degrees of
intensity, or even, by the further invasion of the parasites, secondary in-
fective processes in other organs.*
Eecently from Leyden's clinic very interesting studies have been issued
by the brothers Klemperer on the production of immunity and upon
the cure of pneumonia. Immunity is readily obtained in animals either
by subcutaneous or intravenous injections of large quantities of the fil-
tered bouillon cultures, or by the injection of the glycerine extract. The
immunity, though rarely lasting more than six months, was transmitted
to the offspring born within this period. Still more interesting are their
observations upon the cure of the experimentally produced disease. They
found that the serum and fluids of the body of an animal which had been
rendered immune had the property not only of producing immunity
when introduced into the circulation of another susceptible animal, but
actually of curing the disease after infection had been in progress for
some time. In infected animals with a body temperature of from 40" to
41° C, the fever fell to normal in twenty-four hours after the injection of
serum of another animal which possessed immunity. They believe that
the pneumoooccus produces a poisonous albumen (pneumotoxin) which
when introduced into the circulation of an animal causes elevation of
temperature and the subsequent production in the body of a substance
* Sfio on the question of etiology the elaborate essay of Wells, Journal of the Ameri-
can Medical Association, 1889.
514 DISEASES OF THE RESPIRATORY SYSTEM.
(antipneumotoxin) which possesses the power of neutralizing the poison-
ous albumen which is formed by the bacteria. In man they hold that
during the pneumonic process there is a constant absorption into the cir-
culation of this poisonous albumen produced by the bacteria in the lungs.
This continues until eventually the same antidotal substance is produced
in the circulation that has been seen to occur experimentally. It is then
that the crisis occurs. The bacteria are neither destroyed nor is their
power to produce the poisonous albumen lessened, but the third factor,
the antitoxic element, now exists and neutralizes the toxic substances as
they are produced. They demonstrated that the serum of the blood of
patients after the crisis of pneumonia contained the antitoxic substance
and was capable, in a fair number of cases, of curing the disease when in-
jected into infected animals. They have made preliminary observations
upon patients with a view of inducing the crisis by the injection of the
blood serum of persons convalescent from pneumonia, and which conse-
quently contains the antitoxic body. In six pneumonic patients the re-
sults were promising. In all there was a decided fall of temperature in
from six to twelve hours after subcutaneous injections of from four to six
c. c. of the serum. The pulse and respirations w^ere also diminished in
frequency. In two cases the temperature fell to 37° C. Twice it fell and
remained at normal. In the other cases it fell only temporarily. In two
typhoid cases the injections were negative. The serum has no effect when
injected into healthy individuals.
Morbid Anatomy. — Since the time of Laennec, pathologists have
recognized three stages in the inflamed lung — engorgement, red hepatiza-
tion, and gray hepatization.
In the stage of engorgement the lung tissue is deep red in color, firmer
to the touch, and more solid, and on section the surface is bathed with
blood and serum. It still crepitates, though not so distinctly as healthy
lung, and excised portions float. The air-cells can be dilated by in-
sufflation from the bronchus. Microscopical examination shows the
capillary vessels to be greatly distended, the alveolar epithelium swollen,
and the air-cells occupied by a variable number of blood-corpuscles and
detached alveolar cells. In the stage of red hepatization the lung tissue
is solid, firm, and airless. If the entire lobe is involved it looks volumi-
nous, and shows indentations of the ribs. On section the surface is dry,
reddish brown in color, and has lost the deeply congested appearance of
the first stage. One of the most remarkable features is the friability ; in
striking contrast to the healtliy lung, which is torn with difficulty, a
hepatized organ can be readily broken by the finger. Careful inspection
shows that tlie surface is distinctly granular, the granulations represent-
ing fibrinous plugs filling tlie air-cells. The distinctness of this appear-
ance varies greatly with the size of the alveoli, which are about O'lO mm. in
diameter in the infant, 0-15 or 0-16 in the adult, and from 0*20 to 0-25 in
old age. On scraping the surface with a knife a reddish viscid serum is
PNEUMONIA. 515
removed, containing small granular masses. The smaller })ronchi often
contain fibrinous plugs. If the lung has been removed before the heart,
it is not uncommon to find solid moulds of clot filling the blood-vessels.
Microscopically, tlie air-cells are seen to be occupied by coagulated fibrin
in the meshes of which are red blood-corpuscles, polynuclear leucocytes,
and alveolar epithelium. The alveolar walls are infiltrated and leucocytes
are seen in the interlobular tissues. Cover-glass preparations from the
exudate, and thin sections show, as a rule, the diplococci already referred
to, many of which are contained within cells. Staphylococci and strep-
tococci may also be seen in some cases. In the stage of gray hepatization
the tissue has changed from a reddish-brown to a grayish-white color.
The surface is moister, the exudate obtained on scraping is more turbid,
the granules in the acini are less distinct, and the lung tissue is still more
friable. Histologically, in gray hepatization, it is seen that the air-cells
are densely filled with leucocytes, the fibrin network and the red blood-
corpuscles have disappeared. A more advanced condition of gray hepa-
tization is that known di?> purulent infiltration^ in which the lung tissue is
softer and bathed with a purulent fluid.
The stage of gray hepatization appears to be the first step in the
process of resolution. The exudate is softened, the cell elements are
disintegrated and rendered capable of absorption. When the purulent
infiltration of the lung tissue reaches the grade sometimes seen post
mortem, it is probable that resolution could not take place. Small abscess
cavities may arise, and by their fusion larger ones. Often in one lung,
or even in one lobe, the various stages of the process may be seen, and the
passage of the engorgement into red hepatization and of the latter into
the gray stage can be readily traced.
The general details of the morbid anatomy of pneumonia may be
gathered from the following facts, based on 100 autopsies, made by me at
the General Hospital, Montreal : In 51 cases the right lung was affected ;
in 32, the left; in 17, both organs. In 27 cases the entire lung, with the
exception, perhaps, of a narrow margin at the apex and anterior border,
was consolidated. In 34 cases, the lower lobe alone was involved; in 13
cases, the upper lobe alone. When double, the lower lobes were usually
afi'ected together, but in three instances the lower lobe of one and the
upper lobe of the other were attacked. In three cases also, both upper
lobes were affected. Occasionally the disease involves the greater part of
both lungs ; thus, in one instance the left organ with the exception of the
anterior border was uniformly hepatized, while the right was in a stage
of gray hepatization, except a still smaller portion in the corresponding
region. In a third of the cases, red and gray hepatization existed together.
In 22 instances there was gray hepatization. As a rule the unaffected
portion of the lung is usually congested or cedematous. When the greater
portion of a lobe is attacked, the uninvolved part may be in a state of almost
gelatinous a^dema. The unaffected lung is usually congested, particularly
516 DISEASES OF THE RESPIRATORY SYSTEM.
at the posterior part. 'J'liis, it must be remembered, may be largely due to
post-mortem subsidence. The uninflamed portions are not always con-
gested and oedematous. The upper lobe may be dry and bloodless when
the lower lobe is uniformly consolidated. The average weight of a normal
lung is about 600 grammes, while that of an inflamed organ may be 1,500,
2,000, or even 2,500 grammes.
The bronchi contain, as a rule, at the time of death a frothy serous
fluid, rarely the tenacious mucus so characteristic of pneumonic sputum.
The mucous membrane is usually reddened, rarely swollen. In the affected
areas the smaller bronchi often contain fibrinous plugs, which may extend
into the larger tubes, forming perfect casts. The bronchial glands are
swollen and may even be soft and pulpy. The pleural surface of the
inflamed lung is invariably involved when the process becomes superficial.
Commonly, there is only a thin sheeting of exudate, producing slight
turbidity of the membrane. In only two of the hundred instances the
pleura was not involved. In some cases the fibrinous exudate may form a
creamy layer an inch in thickness. A serous exudation of variable amount
is not uncommon.
Lesions in other Organs. — The heart is distended with firm, tenacious
coagula, which can be withdrawn from the vessels as dendritic moulds.
In no other acute disease do we meet with coagula of such solidity and
firmness. The distention of the right chambers of the heart is particu-
larly marked. The left chambers are rarely distended to the same degree.
The spleen is often enlarged, though in only 35 of the 100 cases was the
weight above 200 grammes. The kidneys show parenchymatous swelling,
turbidity of the cortex, and, in a very considerable proportion of the cases
— twenty-five per cent — chronic interstitial changes.
Pericarditis is not infrequent, and occurs more particularly with pneu-
monia of the left side and with double pneumonia. In 5 of the 100 autop-
sies it was present, and in 4 of them the lappet of lung overlying the peri-
cardium with its pleura was involved. Endocarditis is more frequent and
occurred in IG of the 100 cases. In 5 of these the endocarditis was of the
simple character ; in 11 the lesions were ulcerative. Fatty degeneration
of the heart is not common except in protracted cases.
Meningitis is not infrequently found, and in many cases is associated
with malignant endocarditis. It was present in 8 of the 100 autopsies.
Of twenty cases of meningitis in ulcerative endocarditis fifteen occurred
in pneumonia. The meningeal inflammation in these cases is usually
cortical.
Croupous or diphtlieritic inflammation may occur in other parts. A
croupous colitis, as pointed out by Bristowe, is not very uncommon. It
occurred in 5 of my 100 post-mortems. It is usually a thin, flaky exuda-
tion, most marked on the tops of the folds of the mucous membrane. In
one case tlicre was a patch of croupous gastritis, covering an area of 12 by
8 cm., situated to the left of the cardiac orifice.
PNEUMONIA. 517
The liver sliows pjircnchymatous cliuiigos juhI often extreme engorge-
ment of tlie heinitic veins.
Symptoms. — Abruptly, or preceded })y a, day or two of indisposi-
tion, the patient has a severe chill, lasting from ten to thirty minutes. In
.no acute disease is an initial chill so constant or so severe. The fever
rises quickly. There is pain in the side, often of an agonizing character.
A short, dry, painful cough soon develops, and the respirations are in-
creased in frequency. When seen on the second or third day the patient
presents an appearance which may be quite pathognomonic. He lies flat
in bed, often on the affected side ; the face is flushed, particularly the
cheeks ; the breathing is hurried ; the aliB nasi dilate with each inspira-
tion ; the eyes are bright, the expression is anxious, and there is a frequent
short cough which makes the patient Avince and hold his side. The ex-
pectoration is blood-tinged and extremely tenacious. The temperature
rises rapidly to 104° or 105°. The pulse is full and bounding and the
pulse-respiration ratio much disturbed. Examination of the lung shoAVS
the physical signs of consolidation — blowing breathing and fine rales.
After persisting for from seven to ten days the crisis occurs, and with a
fall in the temperature the patient passes from a condition of extreme dis-
tress and anxiety to one of comparative comfort.
The fever of pneumonia rises abruptly with the chill, during which
the rectal temperature may be high. In children and in cases without
chill the rise is more gradual. The temperature reaches 104° or 105° and
is continuous, with a variation of a degree to a degree and a half. If
a two-hour record is kept the diurnal variations are seen to follow the
normal type. In children and healthy adults the fever is usually higher
than in old persons and drunkards. After continuing for from five to
nine days the temperature falls abruptly, forming what is known as the
crisis^ so characteristic in a large proportion of the cases. In from five
to twelve hours the temperature may fall eight degrees. The crisis may
occur as early as the third day or as late as the twelfth or fourteenth. A
pseudo-crisis may occur on the fifth day or earlier. Defervescence may
take place gradually by lysis. In cases of delayed resolution the fever
may persist for weeks.
Respiratory Symptoms. — Pain of an agonizing character is an early
and distressing symptom. It is usually referred to the nipple or axillary
regions of the affected side. In exceptional cases it may be in the abdo-
men or flank, or even beneath the shoulder-blade. Deep inspiration and
cough aggravate it. Dyspncea is a very prominent feature. The respira-
tions may be from forty to sixty in the minute and in exceptional cases
and in children may rise to eighty. To produce this shortness of breath
many fac^tors combine; — the fever, the loss of function in a considerable
area of lung tissue, and the excessive pain in the side, which makes it im-
possible to draw a d(;ep breath. There may be nervous factors at work,
as with the (crisis the number of res2)irations may fall nearly to normal.
518
DISEASES OF THE KESPIRATORY SYSTEM.
while the consolidation of the lung still persists. The type of breathing
in pneumonia is peculiar and almost distinctive. The inspirations are
Jnn. if) ii 12 13 n ir, in n ifi /g
Resp.
75
70
C5
60
55
50
15
10
35
30
25
20
15
10
Pnlse
190
180
170
ICO
150
140
130
120
110
100
90
80
70
60
50
40
Temp,
109
108
107
106
105
101
1C3
102
101
100
99
98
96
Temp.
Pulse
Resp.
Stools
Urine
3ay of
iiicasc
£!
10
11
12
13
14
BLACK, temperature; red, pulse; blue, respiration
Chart XV.— Fever, pulse, and respirations in lobar pneumonia.
short and superficial. Expiration is often associated with a short grunt.
The ratio between the respirations and pulse may be 1 to 2, or even 1 to
PNEUMONIA. 519
1-5. Ill no other disease do we see sucli marked disturbance in the pulse-
respiration ratio, and this is sometimes an aid in diagnosis.
The cougli is also very characteristic — frequent, short, restrained, and
associated witli great pain in the side. It is at first dry, hard, and with-
out expectoration. In old persons and drunkards and in those debilitated
by long illness there may be no cough. The sputum is mucoid at first,
but within twenty-four hours shows special features. A brisk lia3moptysis
may be an initial symptom. Pneumonic sputum is viscid, tenacious, and
blood-tinged. The gummous viscidity, together with the red blood-cor-
puscles in various stages of alteration, give pathognomonic characters to
the sputa, unknown in any other disease. The rusty tinge becomes more
marked as the disease progresses, and so tenacious is the expectoration
that it has to be wiped from the lips of the patient, and a spit-cup, half
full, may be inverted without spilling. Toward the close it becomes
more liquid and is more readily expelled. In low types of the disease the
sputum may be fluid and dark brown, resembling prune juice. The
amount is very variable. In children and old people there may be none ;
ordinarily, however, there are from 100 to 300 c. c. daily. After the crisis
the quantity is variable ; abundant in some cases, absent in others. Micro-
scopically, the sputum contains red blood-corpuscles in all stages of de-
generation, alveolar epitheliu*m, diplococci and other micro-organisms,
cell-moulds of the alveoli, and, in some cases, small fibrinous casts of the
bronchioles. The latter are sometimes plainly visible to the naked eye.
Physical Signs. — Inspection may not at first show any difference be-
tween the two sides, though usually if the lower lobe of a lung is involved
the movement is less on the affected side. Later, when consolidation has
occurred, particularly if it is massive, this deficient expansion is very
marked. Mensuration may show a definite increase in the volume of the
side involved. The intercostal spaces are not obliterated. Palpation in-
dicates still more clearly the lack of expansion, and a pleural friction may
be felt. Tactile fremitus is increased. These signs are all more marked
when consolidation is established.
Percussion. — In the stage of engorgement the note is higher pitched
and may have a somcAvhat tympanitic quality, the so-called Skoda's reso-
nance. This can often be obtained over the lung tissue just above a con-
solidated area. When the lung is hepatized, the percussion note is flat,
the quality of the flatness varying a good deal from a note which has in it
a certain tympanitic quality to absolute dulness. There is not the wooden
flatness of effusion and the sense of resistance is not so great. During
resolution tlie tympanitic quality of the percussion note may return. For
weeks or months after convalescence there may be a higher-pitched note
on the affected side.
Auscultation. — Quiet, suppressed breathing in the affected part is often
a marked feature in the early stage, and is always suggestive. Very early
there is heard at the end of inspiration the fine crepitant rale, a series of
520 DISEASES OF THE KESPIRATORY SYSTEM.
minute cracklings heard close to the ear, and perhaps not audible until a
full breath is drawn. Whether this is a fine pleural crepitus or is pro-
duced in the air-cells and finer bronchi is still an open question. At this
stage, before consolidation has occurred, the breath-sounds may be, as
before mentioned, much feebler than in health, but on drawing a long
breath they may have a harsh quality, to which the term broncho-vesicular
has been applied. In the stage of red hepatization and when dulness is
well defined, the respiration is tubular, similar to that heard in health over
the larger bronchi. AVith this blowing breathing there may be no rales,
and it may present an intensity unknown in any other pulmonary affec-
tion. It is simply the propagation of the laryngeal and tracheal sounds
through the bronchi and the consolidated lung tissue. The permeability
of the bronchi is essential to its production. Tubular breathing is absent
in certain cases of massive pneumonia in which the larger bronchi are
completely filled with exudation. When resolution begins mucous rales of
all sizes can be heard. At first they are small and have been called the
redux-crepiUcs. The voice-sounds are transmitted through the consoli-
dated lung with great intensity. This bronchophony may have a curious
nasal quality to which the term segophony has been given.
Circulatory Symptoms. — During the chill the pulse is small, but in
the succeeding fever it becomes full and bounding. In cases of moderate
severity it ranges from 100 to 116. It is not often dicrotic. In strong,
liealthy individuals and in children there may be no sign of failing pulse
throughout the attack. With extensive consolidation the left ventricle
may receive a very diminished amount of blood and the pulse in conse-
quence may be small.
In the old and feeble the pulse may be small and rapid from the
outset. The heart-sounds are usually loud and clear. During the in-
tensity of the fever, particularly in children, hruits are not uncommon
both in the mitral and in the pulmonary areas. The second sound over
the pulmonary artery is accentuated. Attention to this sign gives a valu-
able indication as to the condition of the lesser circulation. With disten-
tion of the right chambers and failure of the right ventricle to empty
itself completely the pulmonary second sound becomes much less distinct.
When the right heart is engorged there may be an increase in the dulness
to the right of the sternum. With gradual heart-failure and signs of
dilatation the long pause is greatly shortened, the sounds approach each
other in tone and have a foetal character (embryocardia).
Blood. — The number of red corpuscles is reduced, but, in consequence
of the comparative shortness of the attack, we rarely see the ana?mia asso-
ciated with other febrile disorders. No special changes occur in the cor-
puscles themselves. Tlie colorless corpuscles are increased in number from
about 0,000 per c. mm., the normal number, to 10,000, or even more. This
leucocytosis disappears as soon as crisis occurs. Its absence during the
fastigium is considered to indicate an unfavorable prognosis. A striking
PNEUMONIA. 521
feature in the blood-slide is the richness and density of the fibrin net-
work. This corresponds to the great increase in the fibrin elements,
which has long been known to occur in pneumonia, the proportion rising
from four to ten parts per thousand. Hayem describes the blood-plates
as greatly increased. The diplococci- can very rarely be demonstrated in
the blood.
The gastro-intestinal symptoms are those associated with an ordinary
sthenic fever. Vomiting is not frequent at the outset. There is naturally
loss of appetite. The tongue is white and furred, and, in cases of a low
tvpe, rapidly becomes dry. Constipation is more common than diarrhoea,
w^hich does prevail, however, in some epidemics. The spleen is usually
enlarged, and the edge can be felt during a deep inspiration. Except in
cases of extreme engorgement of the right heart, the liver is usually not
increased in volume.
Among cutaneous symptoms one of the most interesting is the associa-
tion of herpes with pneumonia. Xot excepting malaria, we see labial
herpes more frequently in this than in any other disease, occurring, as it
does, in from twelve to forty per cent of the cases. It is supposed to be
of favorable prognosis, and figures have been quoted in proof of this asser-
tion. It may also occur on the nose or on the genitals. Its significance
and relation to the disease are unknown. It is scarcely necessary to men-
tion the theory w^hich has been advanced, that it is an external expression
of a neuritis which involves the pneumogastric and induces the pneumo-
nia. At the height of the disease sweats are not common, but at the crisis
they may be profuse. Redness of one cheek is a phenomenon long recog-
nized in connection with pneumonia, and is usually on the same side as
the disease.
The urine presents the usual febrile characters of high color, high spe-
cific gravity, high density, and increased acidity. The nitrogenous ele-
ments, urea and uric acid, are notably increased. The chlorides are
absent, or greatly reduced, during the height of the fever — due, it is sup-
posed, to the amount exuded in the hepatized lung. At the crisis there may
be marked increase in the amount of urine, which is heavily laden with
urates and extractives. When jaundice occurs there is bile-pigment. A
trace of albumen is present in a large proportion of the cases. It is rarely
of serious significance, and seldom associated with tube-casts.
Cerebral Symptoms. — As an initial symptom, headache is common.
Consciousness is usually retained throughout, even in severe cases. In
children convulsions are common, and in at least one half the cases usher
in the disease. There may be violent maniacal symptoms in the adult. I
once performed an autopsy in a case of this kind in which there was no
suspicion whatever that the disease was other than acute mania. In drunk-
ards the symptoms from the outset may be those of delirium tremens, in
which disease it should be an invariable rule, even if fever is not present,
to examine the lungs. These patients are apt to wander about, and must
522 DISEASES OF THE RESPIRATORY SYSTEM.
be carefully watched. The preliminary excitement and delirium may give
place to hebetude, which deepens to coma. It is not possible to decide in
these cases whether meningitis is present or not, since it is usually cortical,
and there are no symptoms of pressure on the nerves. In only one of
eight instances was there involvement of the base, rendering clear the
diagnosis of meningitis. These cases of so-called cerebral pneumonia are
frequently associated with very high fever. In senile and alcoholic pneu-
monia, however, the temperature may be low and yet brain symptoms
very pronounced. Mental disturbance may persist during and after con-
valescence, and insanity develops in a few cases. It is currently stated
that apex pneumonia is more often complicated with severe delirium, but
it has not been so in my experience.
Complications. — Many of these seem to depend directly on the in-
vasion of the body by the diplococci.
As already mentioned, pleurisy is an inevitable event when the inflam-
mation reaches the surface of the lung, and thus can scarcely be termed
a complication. But there are cases in which the pleuritic features take
the first place — cases to which the term pleuro-pneumonia is applicable.
The exudation may be sero-fibrinous with copious effusion, differing from
that of an ordinary acute pleurisy in the greater richness of the fibrin,
which may form thick, tenacious, curdy layers. Pneumonia on one side
with extensive pleurisy on the other is sometimes a puzzling complication
to diagnose and an aspirator needle may be required to settle the ques-
tion. The bacteriological examination of the fluid has demonstrated, in a
large number of cases, the presence of the pneumococcus. Of late, special
attention has been paid to the frequency with which empyema compli-
cates pneumonia. Effusion may not have been suspected during the
height of the disease, but after the temperature has been normal for some
days a slight rise occurs and the irregular fever persists. Dulness con-
tinues at the base, or may have extended. The breathing is feeble and
there are no rdles. Such a condition may be. closely simulated, of course,
by the thickened pleural layers which are so commonly found after the
pneumonia. The question should be settled at once by the introduction
of the needle. It is by no means an uncommon complication, and many
cases of empyema supposed to be primary are in reality secondary to a
slight pneumonia.
Pericarditis is more common in the pneumonia of children, particu-
larly when double, and it is said with the pneumonia of the left side. It
was present, as I stated, in five of my one hundred autopsies, Tliough
usually plastic, there may be much serous effusion. There is rarely any
difficulty in the diagnosis, but when the pneumonia involves the portion
of lung covering the pericardium, there may be difficulty in determining,
by physical signs, the existence of fluid. The increase in the dyspnoja,
the greater feebleness of the pulse, and the gradual suppression of the
heart-sounds will give the most valuable indications. In some instances
PNEUMONIA. 523
the fluid is purulent. Though a very serious event, it is surprising how
often recovery takes place even in the most desperate cases of pneumonia
complicated with pericarditis. I remember that the late Dr. Murchison
some years ago commented upon this feature in a case at St. Thomas's
Hospital.
Endocarditis is still more frequent, and in my one hundred autopsies
was present in sixteen. I called attention in the Gulstonian lectures for
1885 to the great frequency of this complication. Of 209 cases of malig-
nant endocarditis collected from the literature, 54 cases occurred in this
disease. Subsequent observations have fully confirmed this statement. It
may be said that with no acute febrile disease is endocarditis so frequently
associated. It is much more common in the left heart than in the right.
It is particularly liable to attack persons with old valvular disease. There
may be no symptoms indicative of this complication even in very severe
cases. It may, however, be suspected in cases (1) in which the fever is
protracted and irregular ; (2) when signs of septic mischief arise, such as
chills and sweats ; (3) when embolic phenomena appear. The frequent
complication of meningitis with the endocarditis of pneumonia, which has
already been mentioned, gives prominence to the cerebral symptoms in
these cases. The physical signs may be very deceptive. There are in-
stances in which no cardiac murmurs have been heard. In others the de-
velopment under observation of a loud, rough murmur, particularly if
diastolic, is extremely suggestive.
Changes in the myocardium are not uncommon, rarely more, however,
than cloudy swelling of the fibres ; but in some instances there is fatty
change.
Ante-mortem heart-clots are rare in pneumonia, even in the extreme
grade of dilatation of the right chamber. In not a single instance of my
autopsies were there globular thrombi in the auricles or in apices of the
ventricles. In protracted cases thrombi occasionally form in the veins.
A rare complication is embolism of one of the larger arteries. I saw an
instance in Montreal of embolism of the femoral artery at the height of
pneumonia, which necessitated amputation at the thigh. The patient re-
covered.
By far the most important complication is the pneumonic meningitis^
which varies much at different times and in different places. My Mont-
real experience is rather exceptional, as eight per cent of the fatal cases had
this complication. It usually comes on at the height of the fever and in
the majority of the cases is not recognized unless, as before mentioned, the
base is involved, which is not common. Meningitis may develop later in
the disease and is then more easily diagnosed. Associated as it so often
is with ulcerative endocarditis, there may be embolism of the cerebral
arteries, inducing hemiplegia. Among rare complications maybe men-
tioned peripheral neuritis^ of which several instances have been described.
I saw one well-marked instance, following pneumonia and influenza, in the
84
524 DISEASES OF THE RESPIRATOIIY SYSTEM.
spring of 1890. There was neuritis of the left arm with considerable
wasting.
Serious gastric complications are rare. A croupous gastritis has already
been mentioned. The croupous colitis may induce severe diarrhoea.
Jaundice is one of the most interesting complications of pneumonia and
occurs with curious irregularity in different outbreaks of tlie disease. It
sets in early, is rarely very intense, and has not the characters of obstruct-
ive jaundice. There are cases in which it assumes a very serious form.
The mode of production is not well ascertained. It does not appear to
bear any definite relation to the degree of hepatic engorgement and it is
certainly not due to catarrh of the ducts. Possibly it may be, in great
part, haematogenous.
Parotitis occasionally occurs, commonly in association with endocar-
ditis.
A rare complication of pneumonia is an arthritis resembling rheuma-
tism, which may come on gradually during the disease or in the conva-
lescence.
Brighfs disease does not often follow pneumonia. Peritonitis is ex-
ceedingly rare.
Relapse in pneumonia is so uncommon that some good observers have
doubted its occurrence. I have never seen an instance in which I was
certain that there was a definite relapse. There are cases in which from
the ninth to the eleventh day the fever subsides, and after the tempera-
ture has been normal for a day or two, a rise occurs and fever may persist
for another ten days or even two weeks. Though this might be termed a
relapse, it is more correct to regard it as an instance of an anomalous
course of delayed resolution. Wagner, who has studied the subject care-
fully, says that in his large experience of 1,1.00 cases he met with only
3 doubtful cases. When it does occur, the attack is usually abortive and
mild.
Recurrence is more common in pneumonia than in any other acute
disease. Rush gives an instance in which there were twenty-eight attacks.
Other authorities narrate cases of eight, ten, and even more attacks.
Formerly it was much disputed whether ordinary lobar pneumonia
ever terminated in pulmonary phthisis. These are really cases of tuber-
culo-pneumonic phthisis the onset of which may resemble acute pneu-
monia.
Clinical Varieties. — A number of dilTcrent forms of pneumonia have
been recognized, such as malignant, adynamic, bilious, malarial, rheu-
matic, and the like, but they scarcely require a full description. A mala-
rial pneumonia is described and is thought to be very prevalent in some
parts of tliis country. Altliough I have seen during the past seven years
several hundred cases of malaria and am familiar with the bronchial trou-
ble so commonly associated with it, I have yet to see an instance of pneu-
monia which seemed in any way connected with paludism. The so-called
PNEUMONIA. 525
rheumatic pneumonia has, so far as I know, no peculiaritic^s ; nor has
rheumatism, I think, any special relation to the disease. The term
typhoid pneumonia is commonly used to designate cases with adynamic
symptoms and it is to be distinguished from those cases in which typlioid
fever begins with a definite pneumonia, the so-called pneumo-tyjjlius of
foreign writers.
Epidemic pneumonia is, as a rule, more fatal and may display minor
peculiarities which differ in different epidemics. In some the cerebral
complications are marked ; in others, the cardiac. There may be diarrhoea.
The pneumonia which occurs with influenza, and was so common in the
last epidemic, presents no special features other than the peculiarities of
onset. Perhaps, also, it was more severe and more fatal. In diabetic
patients pneumonia runs a rapid and severe course, ending sometimes in
abscess or gangrene. In the subjects of chronic alcoholism the onset of
pneumonia is insidious, the symptoms may be masked, the fever slight,
and the clinical picture may be that of delirium tremens. So latent is
the disease in some of these cases that the thermometer alone may indi-
cate the presence of an acute disease.
At the extremes of life pneumonia presents certain well-marked
features. It is sometimes seen in the new-born. In infants it very
often sets in with a convulsion. The summit of the lung seems more
frequently involved than in adults and the cerebral symptoms are more
marked throughout. The torpor and coma, particularly if they follow
convulsions, and the preliminary stage of excitement, may lead to the
diagnosis of meningitis. Holt has recently published figures which indi-
cate that lobar pneumonia is not uncommon in infants under two years of
age. Pneumonic sputum is rarely seen in children.
In old age pneumonia may be latent, coming on without chill ; the
cough and expectoration are slight, the physical signs ill-defined and
changeable, and the constitutional symptoms out of all proportion to the
extent of the local lesion.
When pneumonia is prevailing extensively, particularly in jails and
garrisons, cases are found which have some of the initial symptoms of the
disease — perhaps a slight chill, moderate fever, and a few indefinite local
signs. This is the so-called larval pneumonia. Apex pneumotiia is said
to be more often associated with adynamic features and with marked
cerebral symptoms. The expectoration and cough may be slight. I can-
not say that in my experience the cerebral symptoms in adults have been
more marked in this form, nor do I think it necessarily graver than if
situated at the base.
The creeping or migratory pneumonia successively involves one lobe
after the other and is a peculiar and well-recognized variety.
Douhle pneumonia presents no peculiarities other than the greater dan-
ger connected with it. The term massive pneumonia is applied to the rare
condition in which not alone tlie air-cells but the bronchi of the entire
526 DISEASES OF THE RESPIRATORY SYSTEM.
lobe or even of the lung are filled with the fibrinous exudate. The aus-
cultatory signs are absent ; there is neither fremitus nor tubular breath-
ing, and on percussion the lung is jibsolutely flat. It closely resembles
pleurisy with effusion. The moulds of the bronchi may be expectorated
in violent fits of coughing.
Prognosis. — In a disease which carries off one in every four or five
of those attacked the prognosis in a large number of cases is necessarily
grave. In children and in healthy adults the outlook is good. In the
debilitated, in drunkards, and in the aged the chances are against recovery.
So fatal is it in the latter class that it has been termed the natural end of
the old man. Many circumstances, of course, influence prognosis, par-
ticularly the extent of the disease, the height of the fever, the presence of
other diseases, and the occurrence of complications.
When a lower lobe on one side or the lower and middle lobes of the
right side are involved in a healthy adult, if there are no complications,
the case usually proceeds to satisfactory resolution. Meningitis is a fatal
complication. Endocarditis is extremely grave, much more so than peri-
carditis, from which many cases recover. Early signs of heart-failure,
dilatation of the right chamber, gradual cyanosis, and oedema of the lungs,
are symptoms of the most serious character. As before stated, the danger
of heart-clot is not great in pneumonia. The risk is in the extreme dis-
tention of the right chamber. I believe the firm fibrinous coagula en-
tangled in the columnae carneae and the valves are invariably produced
during the death agony. When there are symptoms of abscess of the lung
or of gangrene the prognosis is extremely bad ; yet cases are on record of
recovery from both these conditions. Increasing rapidity of respiration,
with difficulty in expectoration, very liquid and dark sputa, a low mutter-
ing delirium, dry tongue, and failing pulse, witli a suffused lividity of the
face, are indicative of approaching dissolution. Death rarely occurs
from direct interference wdth the function of respiration, though it may
happen in cases of extensive double pneumonia. In a majority of cases
the fatal result is brought about by gradual heart-failure, whether induced
by the prolonged action of the fever, the specific action of the poison, or
paralysis due to overdistension of the right ventricle. A collateral oedema
of the uninvolved portion of the lung, so much spoken of, rarely, I believe,
occurs in pneumonia ; nor is it likely, if the observations of Welch upon
the production of tliis condition are correct, that in the course of pneu-
monia the left ventricle can be disproportionately weak in comparison
witli the right.
Termination. — Uesohdion^ the process by wliich the lung is restored
to its normal state, is effected partly by expectoration and partly by lique-
faction and absorption of the exudate. It is not always possible to esti-
mate the share respectively taken by these processes. There are cases in
which a rapid resolution of extensive consolidation takes place without
any special increase in the expectoration ; and, on the other hand, during
PNEUMONIA. 527
resolution it is not uncommon to find in the expectoration the little plugs
of fibrin and leucocytes which have been loosened from the air-cells and
expelled by coughing. In a majority of cases both processes are probably
at work. A variable time is taken in the restoration of tlie lung. Some-
times within a week or ten days the "dulness is greatly diminished, the
breath-sounds become clear, and, so far as physicial signs are any guide,
the lung seems perfectly restored. It is to be remembered that in any
case of pneumonia with extensive pleurisy a certain amount of dulness
will persist foi months, owing to thickening of the pleura. Delayed reso-
lution is a condition which causes much anxiety to the physician. It may
be postponed until the fourth, eighth, or even the tenth week. Usually
the fever subsides, but the consolidation of the lung may persist, with
great improvement in the general condition of the patient. In apex
pneumonia the resolution is more apt to be retarded. It has been stated
that bleeding is one cause of delayed resolution. A solid exudation can
persist for weeks and yet the integrity of the lung may be ultimately re-
stored. Grissole describes the lung from a patient who died on the six-
tieth day in which the affected part looked not unlike the acute disease.
Abscess may result from purulent infiltration of the lung tissue. It
occurred in 4 of my 100 cases. Usually the lung breaks in limited areas
and the abscesses are not large, but they may involve a considerable por-
tion of a lobe. This most serious complication is indicated by cavern-
ous signs and the expectoration of purulent material containing elastic
tissue. The constitutional symptoms are usually very severe. In a large
majority of the clinical cases in which abscess of the lung is believed
to follow an acute pneumonia, the process has in reality been rapid tuber-
culous consolidation with breaking of the lung tissue. There can, how-
ever, be no reasonable doubt that abscess of the lung does occur as a rare
sequence of ordinary pneumonia.
Gangrene. — The presence of this complication is rendered evident by
the horribly fetid odor of the expectoration, the presence of lung tissue,
and crystals of fatty acids. It occurred in 3 of my 100 autopsies.
Fibroid Lidurafion. — That a chronic interstitial pneumonia may fol-
low the ordinary acute disease cannot be questioned, though it is probably
the rarest of all terminations. It was present in one of my 100 autopsies.
The patient, aged fifty-eight, died on the thirty-second day after the initial
chill. The right lung was uniformly solid, grayish in color, firm, and
presented in places a translucent, smooth, homogeneous aspect. In these
areas the alveolar walls were thickened and the fibrinous plugs filling the
air-cells were undergoing transformation into a new growth of connective
tissue.
Mortality. — Pneumonia is one of the most fatal of acute diseases.
Hospital statistics show that the mortality ranges from twenty to forty
per cent Of 1,012 cases at the Montreal General Hospital, the mortality
was 20-4 per cent. It appears to be somewhat more fatal in southern
528 DISEASES OF THE RESPIRATORY SYSTEM,
climates. Of 3,969 cases treated at the Charity Hospital, New Orleans,
the death rate was 28 '01 per cent. It has been urged that the mortality
in this disease has been steadily increasing, and attempts have been made
to connect this increase with the expectant plan of treatment at present
in vogue. But the careful and thorough analysis by C. N. Townsend and
A. Coolidge, Jr.,* of 1,000 cases at the Massachusetts General Hospital
indicates clearly that, when all circumstances are taken into consideration,
this conclusion is not justified. They found that when all fatal cases
over fifty years of age were omitted, and those patients who were delicate,
intemperate, or the subject of some complication, there was very little
variation from decade to decade, and that, excluding these cases, the rate
was but little over ten per cent. In answer to the assertion that the
modified treatment is in part responsible for the increased mortality, these
authors show clearly that the rise in death rate took place in the period
prior to 1860, when the treatment was entirely or in great part heroic.
According to the recent analysis of 708 cases at St. Thomas's Hospital
by Hadden, H. W. G. McKenzie, and W. W. Ord, the mortality progress-
ively increases from the twentieth year, rising from 3-7 per cent under
that age to 22 per cent in the third decade, 30-8 per cent in the fourth,
47 per cent in the fifth, 51 per cent in the sixth, 65 per cent in the sev-
enth decade.
Diagnosis. — No disease is more readily recognized in a large majority
of the cases. The external characters, the sputa, and the physical signs
combine to make one of the clearest of clinical pictures. After a study
in the post-mortem room of my own and others' mistakes, I think that
the ordinary lobar pneumonia of adults is rarely overlooked. Judging
from my autopsy records, I should say that errors are particularly liable
to occur in the intercurrent pneumonias, in those comnlicating chronic
affections, and in the disease as met with in children, the aged, and
drunkards. Tuberculo-pneumonic phthisis is frequently confounded with
pneumonia. Pleurisy with effusion is, I believe, not often mistaken ex-
cept in children.
In diabetes, Bright's disease, chronic heart-disease, pulmonary phthisis,
and cancer, an acute pneumonia often ends the scene, and is frequently
overlooked. In these cases the temperature is perhaps the best index,
and should, more particularly if cough develops, lead to a careful exami-
nation of the lungs. The absence, however, of expectoration and some-
times the entire absence of pulmonary symptoms makes a diagnosis very
difficult.
In children there are two special sources of error; the disease may be
entirely masked by the cerebral symptoms and the case mistaken for one
of meningitis. It is remarkable in these cases how few indications there
are of pulmonary trouble. The other condition is pleurisy with effusion,
* Boston Medical and Surgical Journal, 1889.
PNEUMONIA. * 529
which in children often has deceptive physical signs. The breathing
may be intensely tubular and tactile fremitus may be present. 'J'he
exploratory needle is sometimes required to decide the question. In the
old and debilitated a knowledge that the onset of pneumonia is insidious,
and that the symptoms are ill-defined iind latent, should place the practi-
tioner on his guard and make him very careful in the examination of the
lungs in doubtful cases. In chronic alcoholism the cerebral symptoms
may predominate and completely mask the local disease. As mentioned,
the disease may assume the form of violent mania, but more commonly
the symptoms are those of delirium tremens. In any case rapid pulse,
rapid respiration, and fever are symptoms which should invariably excite
suspicion of inflammation of the lungs.
Pneumonia is rarely confounded with ordinary consumption, but to
differentiate acute tuberculo-pneumonic phthisis is often difficult. The
case may set in with a chill. It may be impossible to determine which
condition is present until softening occurs and elastic tissue and tubercle
bacilli appear in the sputum. A similar mistake is sometimes made in
children. With typhoid fever, pneumonia is not infrequently confounded.
There are instances of pneumonia with the local signs well marked in
which the patient rapidly sinks into what is known as the typhoid state,
with dry tongue, rapid pulse, and diarrhoea. Unless the case is seen from
the outset it may be very difficult to determine the true nature of the
malady. On the other hand, there are cases of tjrphoid fever which set
in with symptoms of lobar pneumonia — the so-called pneumo-typhus. It
may be impossible to make a differential diagnosis in such a case unless
the characteristic eruption develops.
Treatment. — Pneumonia is a self -limited disease, and runs its course
uninfluenced in any way by medicine. It can neither be aborted nor cut
short by any known means at our command. Even under the most un-
favorable circumstances it will terminate abruptly and naturally, without a
dose of medicine having been administered. A patient was admitted into
one of my wards at the Philadelphia Hospital on the evening of the seventh
day after the chill, in which he had been seen by one of my assistants, who
had ordered him to go to hospital. lie remained, however, in his house
alone, without assistance, taking nothing but a little milk and bread and
whisky, and was brought into the hospital by the police in a condition of act-
ive delirium. That night his temperature was 105° and his pulse above 120.
In his delirium he came near escaping through tlie window of the ward.
The following morning — the eighth day — the crisis occurred, and at ward
class his temperature was below OS"". The entire lower lobe of the right
side was found involved, and he entered upon a rapid convalescence. So
also, under the favoring circumstances of good nursing and careful diet,
the experience of many physicians in different lands has shown that pneu-
monia runs its course in a definite time, aborting sometimes spontaneously
on the third or tlie fifth day, or continuing until the tenth or twelfth.
530 DISEASES OF THE RESPIRATORY SYSTEM.
We have, then, no specific treatment for pneumonia. In cases of
moderate severity a purely expectant plan may be followed — keeping the
bowels open, regulating the diet, and, if necessary, giving a Dover's pow-
der at night to procure sleep. In severer cases a symptomatic plan of
treatment should be pursued, meeting the indications as they arise. The
first distressing symptom is usually the pain in the side, which may be
relieved by local depletion — by cupping or leeching — or, better still, by a
hypodermic injection of morphia. In many cases the question comes up
at the outset as to the propriety of venesection. The reproach of Van
Helmont, that " a bloody Moloch presides in the chairs of medicine," can-
not be brought against the present generation of physicians. During the
first five decades of this century the profession bled too much, but during
the last decades we have certainly bled too little. Pneumonia is one of
the diseases in which a timely venesection may save life. To be of service
it should be done early. In a full-blooded, healthy man with high fever
and bounding pulse the abstraction of from twenty to thirty ounces of
blood is in every way beneficial, relieving the pain and dyspnoea, reducing
the temperature, and allaying the cerebral symptoms, so violent in some
instances. Unfortunately, in a majority of the cases, bleeding is now used
at a late stage in the disease, when the heart is beginning to fail, the right
chambers are dilated, the face is of a dusky hue, the respirations are very
rapid, and there are signs, perhaps, of oedema of the uninvolved portions
of the lungs. Though resorted to rather as a forlorn hope, it is a rational
practice, and, in cases of emphysema and of heart-disease, proves satisfac-
tory under identical hydraulic indications, but, unfortunately, in a major-
ity of the cases of pneumonia it proves futile. Time and again, in such
cases, have I urged free venesection, but in twelve hospital patients bled
under these circumstances only one recovered.
In the majority of cases requiring treatment the indications are to
lower the temperature and to support the heart.
Fever alone is not, I think, hurtful ; but it is difficult to diiferentiate
the effects of fever and of the poisons circulating in the blood. It is not
impossible, as some suppose, that the fever may be directly beneficial;
still, high and prolonged pyrexia is undoubtedly dangerous and should be
combated. Of efficient measures cold unquestionably heads the list.
Perhaps the most convenient w^ay is the application of ice-bags to the
affected side — a practice long followed in Germany and now becoming
prevalent in England and America. When the temperature is above 103°
or 103-5° sponging may be resorted to. If the high fever is combined
with brain sym})toms the bath at 70° may be used without risk.
The use of medicinal antipyretics in pneumonia is of doubtful pro-
priety. Quinine has been much vaunted. Personally I cannot speak of any
special advantages which I have seen from its use. From thirty to sixty
grains daily will reduce the tem]ierature, in a certain proportion of the
cases, one or two degrees, but in this respect it is far below other antipy-
PNEUMONIA. 531
retics. It is also not without ill effects in disturbing digestion or even
causing vomiting, and, according to some writers — though this I have
never noticed — inducing marked cardiac weakness and depression. Anti-
pyrin, antifebrin, and phenacetin have had a thorough trijd in pneumonia,
and, although they still have their advocates, the general opinion of clini-
cal physicians seems decidedly against their systematic employment.
The progressive cardiac weakness is, after all, the most important
enemy to fight in pneumonia and is emphasized by the old axiom, Sine
pulsu nulla therapeia. Doubtless this is in part caused by the fever, but
much more important is the toxic action of the poisons produced in the
course of the disease. To these must be added the third factor, over-
distention of the right chambers of the heart. AVe are still without an
agent which can counteract the gradual influence of the poisons which
develop in the course of acute febrile diseases, such as typhoid fever,
pneumonia, and diphtheria, the chief effect of which is exercised upon
the circulation, increasing the rapidity of the pulse and inducing a pro-
gressive heart-failure. To meet this indication the general experience of
physicians still points to alcohol as the most trustworthy remedy. Although
some hold that alcohol in this condition is not indicated, I believe that it
is in many instances the only remedy capable of tiding the patient over
the most dangerous period. It should be given when the pulse becomes
small, frequent, and feeble, or very compressible, and when the heart-
sounds — particularly the second pulmonic sound — begin to lose their
force. The amount will vary with the age of the patient and with his
habits. Beginning with four to six ounces in the day the quantity may
be increased, if necessary, to twelve or sixteen or even twenty ounces.
Of medicinal agents strychnine is one of the most valuable and has
come into favor as a useful cardiac tonic. It may be given in doses of
from a thirtieth to a twentieth of a grain. N"o certainty has as yet been
reached as to the value of digitalis in the failing heart of fever. The
practice is very general, but it is a drug to be used with caution in this
condition. When there are signs of sudden or rapid heart-failure, h3rpo-
dermic injections of ether will sometimes prove most serviceable. Of
other stimulants ammonia is one of the most valuable and is best given in
the form of the aromatic spirits, which is quite as satisfactory and much
less nauseous than the usually administered carbonate of ammonia. Cam-
phor and musk may also be employed.
Following the practice which is employed in spreading erysipelas,
some writers have recommended direct antiseptic injections into the lung
tissue itself. Lepine has used with benefit very dilute bichloride injec-
tions. In cases of gangrene following pneumonia, it might be of advan-
tage to use iodoform oil or bichloride solutions.
The question of the use of arterial sedatives has not yet been settled.
Aconite and veratrum viride and tartar emetic are largely used and loudly
recommended by many physicians. I have never seen such benefit from
532 DISEASES OF THE RESPIRATORY SYSTEM.
their early use as would warrant a recommendation, and when an arterial
sedative is indicated in the robust, full-blooded, healthy individual, I much
prefer tlie lancet.
Expectorants are rarely of any value in pneumonia. If any one wishes
to be convinced of the futility of sucli remedies, let him study their action
on a series of cases of sthenic pneumonia, in which it would be a real gain
to loosen the cough and give to the sputa a certain degree of fluidity. Nor
in the stage of resolution can they be said to be of any special service. In
cases of tardy resolution I have not hesitated to use pilocarpine, as sug-
gested by Eiess.
For the distressing cough and the pain in the side, opium in some form
may be given, either the hypodermic of morphia or, for the cough alone,
Dover's powder. There has been a feeling in the profession that opium was
counter-indicated in pneumonia, but I fully agree with Loomis that it may
be given with safety and with the greatest comfort to the patient. With
marked cerebral symptoms an ice-cap may be used. If there is delirium, the
patient should be carefully watched. For these symptoms the cold bath is
by far the most efificient remedy, and it or the cold pack should be resorted
to without hesitation. For the complications, in the more serious ones,
such as meningitis and endocarditis, but little can be done. Pleurisy
with large effusion may require aspiration. If there is doubt as to the ex-
istence of fluid the exploratory needle should be used. It may be neces-
sary, in pericarditis with extensive effusion, to aspirate the sac.
Careful feeding forms an essential part of the treatment. The diet
should be light and made up of articles which, while nourishing, are not
heavy and not apt to induce flatulency. Milk or milk-whey, broths,
beef-juice, and eggs constitute the main articles of food. The starchy
articles, as a rule, should be excluded, because they tend to induce flatu-
lency. If the milk also has this effect, it is better to use the wliey and
egg-white or beef -juices. Before leaving the question of diet it may be
mentioned that the use of cold drinks, such as soda or Apollinaris water,
not only gives relief to the distressing thirst, but also helps to reduce the
fever, and may diminish slightly the viscidity of the expectoration.
III. CHRONIC INTERSTITIAL PNEUMONIA
(Cirrhosis of Lung).
This consists in the gradual substitution to a greater or less extent of
connective tissue for tlie normal lung. It is a fibroid change which may
have its starting point in the tissue about the bronchi and blood-vessels,
the interlobuhir septa, tlie alveolar walls, or in the pleura. So diverse arc
the different forms and so varied the conditions under which this change
occurs that a proper classification is extremely diflficult. We may recog-
nize, however, two chief forms — the locals which involves only a limited
CHRONIC INTERSTITIAL PNEUMONIA. 533
area of the lung substance, and tlie diffuse^ invading either both lungs or
an entire organ.
Etiology. — Local fibroid change in the lungs is common. It is a
constant accompaniment of tubercle and in every case of phthisis the
chronic interstitial changes play a very important role. In tumors, ab-
scess, gummata, hydatids, and emphysema it also occurs. Fibroid pro-
cesses are frequently met with at the apices of the lung and may be due
either to a limited healed tuberculosis, to fibroid induration in conse-
quence of pigment, or, in a few instances, may result from thickening of
the pleura.
Diffuse Interstitial Pneumonia is met with under the following cir-
cumstances : 1. As a sequence of acute fibrinous pneumonia. Although
extremely rare, this is recognized as a possible termination. From un-
known causes resolution fails to take place. A gradual process of organ-
ization goes on in the fibrinous plugs within the air-cells and the alveolar
walls become greatly thickened by a new growth, first of nuclear and
subsequently fibrillated connective tissue. Macroscopically there is pro-
duced a smooth, grayish, homogeneous tissue which has the peculiar translu-
cency of all new-formed connective tissue. This has been called gray in-
duration. The subsequent history of this form needs more careful study.
A majority of the cases terminate within a few months, and instances
which have been followed from the outset are very rare.
In one of Charcot's cases, quoted by Bastian, death occurred about
three months and a half after the onset of the acute disease and the lung
was two thirds the normal size, grayish in color, and hard as cartilage. In
the only case of the kind which has come under my observation, the pa-
tient died about a month from the onset of the chill. The lung was uni-
formly solid and grayish in color. In certain regions the fibrinous moulds
in the air-cells were fatty, while in others there were areas of a grayish
translucent aspect, firm, smooth, not at all granular, and resembling recent
connective tissue. Microscopically, these areas show^ed advanced fibroid
change and great thickening of the alveolar walls, while the fibrin plugs
of the air-cells were undergoing fibroid transformation.
2. Chronic Br onclio- Pneumonia. — The relation of broncho-pneumonia
to cirrhosis of the lung has been specially studied by Charcot, who states
that it may follow tlie acute or subacute form of this disease. The fibrosis
extends from the bronchi, which are usually found dilated. The alveolar
walls are thickened and the lobules converted into firm grayish masses,
in which there is no trace of normal lung tissue. This process may go on
and involve an entire lobe or even the whole lung. Many of these cases
are tuberculous from the outset.
3. Plcarogenous Interstitial Pneumonia. — Charcot applies this term
to that form of cirrhosis of the lung which follows invasion from the
pleura. Doubt lias Ijocii expressed by some writers whether tliis really
occurs. While Wilson Fox is probably correct in questioning whether an
534: DISEASES OF THE RESPIRATORY SYSTEM.
entire lung can become cirrliosed by the gradual invasion from the pleura,
I think there can be no doubt that there are instances of primitive dry
pleurisy, which, as Sir Andrew Clark has pointed out, gradually com-
presses the lung and at the same time leads to interstitial cirrhosis. This
may be due in part to the fibroid change which follows prolonged com-
pression. In some cases there seems to be a distinct connection between
the greatly thickened pleura and the dense strands of fibrous tissue pass-
ing from it into the lung substance. Instances occur in which one lobe
or the greater part of it presents, on section, a mottled appearance, owing
to the increased thickness of the interlobular septa — a condition which
may exist without a trace of involvment of the pleura. In many other
cases, however, the extension seems to be so definitely associated with pleu-
risy that there is no doubt as to the causal connection betw^een the two
processes. In these instances the lung is removed with great difficulty,
owing to the thickness and close adhesion of the pleura to the chest wall.
4. Chronic Interstitial Pneumonia^ due to inhalation of dust. Zenker
has proposed the term pjieumonokoniosis for the group of diseases due to
the irritating effects of dust in certain occupations, such as coal-mining,
stone-cutting, axe-grinding, and working in iron dust. It is essentially a
chronic broncho-pneumonia leading to fibroid induration, at first nodular
and peribronchial, and finally involving large areas of the lung tissue,
which are converted into dense grayish-brown or black masses. The sub-
ject will receive separate consideration.
The term cirrhosis should be limited strictly to those cases in v/hich
a lung is involved in the fibroid process, whether originating in the
parenchyma or in the pleura. It should not be applied to fibroid phthisis
of tuberculous origin.
Morbid Anatomy. — The disease is unilateral; the chest of the
affected side is sunken, deformed, and the shoulder much depressed. On
opening the thorax the heart is seen drawn far over to the affected side.
The unaffected lung is emphysematous and covers the greater portion of
the mediastinum. It is scarcely credible in how small a space, close to
the spine, the cirrhosed lung may lie. Indeed, it may be overlooked, as
happened in the case of a physician of my acquaintance, who left instruc-
tions that his lung should be sent to Palmer Howard, of Montreal. It
was reported, however, that at the autopsy no lung could be found ! The
adhesions between the pleural membranes may be extremely dense and
thick, particularly in the pleurogenous cases ; but when the disease has
originated in the lung there may be little thickening of the pleura. The
organ is airless, firm, and hard. It strongly resists cutting, and on section
shows a grayisli fibroid tissue of variable amount, through which pass the
blood-vessels and bronchi. The latter may be either slightly or enor-
mously dilated, There are instances in which the entire lung is converted
into a series of bronchiectatic cavities and the cirrhosis is apparent only
in certain areas or at the root. The tuberculous cases can usually be
CHRONIC INTERSTITIAL PNEUMONIA. 535
differentiated by the presence of an apical cavity, not broncliiectatic, and
often large ; and the otlier lung almost invariably shows tuberculous
lesions. There are cases in which it is difficult to determine satisfactorily
the true nature. A question of som^ interest in connection with chronic
interstitial pneumonia is, Do softening and cavity formation ever occur
apart from caseation and tuberculosis ? That is to say, are there cavities
in a cirrhotic lung which may be due to a simple necrosis? Undoubtedly,
though they are rare ; I have seen them in at least two instances of an-
thracosis, and Charcot * refers to them as " ulceres du poumon^'' to dis-
tinguish them from the abscess cavity of acute pneumonia or a tuberculous
cavity. The other lung is always greatly enlarged and emphysematous.
The heart is hypertrophied, particularly the right ventricle, and there
may be marked atheromatous changes in the pulmonary artery. An
amyloid condition of the viscera is found in some cases.
Symptoms and Course. — It is essentially a chronic disease, ex-
tending over a period of many years, and when once the condition is
established the health may be fairly good. In a well-marked case the
patient complains only of his chronic cough, perhaps of slight shortness
of breath. In other respects he is quite well, and is usually able to do
light work. The cases are commonly regarded as phthisical, though there
may be scarcely a symptom of that affection except the cough. There
are instances, however, of fibroid phthisis which cannot be distinguished
from cirrhosis of the lung except by the presence of tubercle bacilli in
the expectoration. As the bronchi are usually dilated, the symptoms and
physical signs may be those of bronchiectasis. The cough is paroxysmal
and the expectoration is generally copious and of muco-purulent or sero-
purulent nature. It is sometimes fetid. Haemorrhage is by no means
infrequent, and occurred in more than one half of the cases analyzed by
Bastian. Walking on the level and in the ordinary affairs of life the patient
may show no shortness of breath, but in the accent of stairs and on exer-
tion there may be dyspnea.
Physical Signs. — Inspection. — The affected side is immobile, retracted,
and shrunken, and contrasts in a striking way with the voluminous sound
side. The intercostal spaces are obliterated and the ribs may even over-
lap. The shoulder is drawn down and from behind it is seen that the
spine is bowed. The heart is greatly displaced, being drawn over by the
shrinkage of the lung to the affected side. AVhen the left lung is affected
there may be a large area of visible impulse in the second, third, and
fourth interspaces. Mensuration shows a great diminution in the affected
side, and with the saddle-tape the expansion may be seen to be negative.
The percussion note varies with the condition of the bronchi. It may be
absolutely dull, particularly at the base or at the apex. In the axilla
there may be a flat tympany or even an amphoric note over a large
* Qiuvres completes de J. M. Charcot, tome v, p. 189.
536 DISEASES OF THE RESPIRATORY SYSTEM.
sacculated bronchus. On the opposite side the percussion note is usually
hyperresonant. On auscultation the breath-sounds have either a cav-
ernous or amphoric quality at the apex, and at the base are feeble, with
mucous, bubbling rales. The voice-sounds are usually exaggerated. Car-
diac murmurs are not uncommon, particularly late in the disease, when
the right heart fails. These are, of course, the physical signs of the dis-
ease Avhen it is well established. They naturally vary considerably, ac-
cording to the stage of the process. The disease is essentially chronic,
and may persist for fifteen or twenty years. Death occurs sometimes from
haemorrhage, more commonly from gradual failure of the right heart with
dropsy, and occasionally from amyloid degeneration of the organs.
The diagnosis is never difficult. It may be impossible to say, without
a clear history, whether the origin is pleuritic or pneumonic. Between
cases of this kind and fibroid phthisis it is not always easy to discriminate,
as the conditions may be almost identical. When tuberculosis is present,
however, even in long-standing cases, bacilli are usually present in the
sputa, and there may be signs of disease in the other lung.
Treatment. — It is only for an intercurrent affection or for an aggra-
vation of the cough that the patient seeks relief. Nothing can be done
for the condition itself. When possible the patient should live in a mild
climate, and should avoid exposure to cold and damp. A distressing
feature in some cases is the putrefaction of the contents of the dilated
tubes, for which the same measures may be used as in fetid bronchitis.
IV. BRONCHO-PNEUMONIA {Capillary Bronchiisi).
This is essentially an inflammation of the terminal bronchus and the
air-vesicles which make up a pulmonary lobule, whence the term broncho-
pneumonia. It is also known as lobular, in contradistinction to lobar pneu-
monia. The term catarrhal is less applicable. The process begins in all
cases with an inflammation of the capillary bronchi, which is a condition
rarely if ever found without involvement of the lobular structures, so that
it is now customary to consider the affections together.
Etiology. — Broncho-pneumonia is as a rule a secondary affection
met with under the following circumstances :
1. As a sequence of the infectious fevers — measles, diphtheria, whoop-
ing-cough, scarlet fever, and, less frequently, small-pox, erysipelas, and
typhoid fever. In children it forms the most serious complication of
these diseases, and in reality causes more deaths than are due directly to
the fevers.* In large cities it ranks next in fatality to infantile diarrhoea.
Following, as it does, the contagious diseases which principally affect
children, we find that a large majority of cases occur during early life.
* Cyclopaedia of the Diseases of Children, vol. ii.
BRONCnO-PNEUMONIA. 537
According to Morrill's Boston statistics, it is most fatal during the first
two years of life. The number of cases in a community increases or de-
creases with the prevalence of measles, scarlet fever, and diphtheria. It is
most prevalent in the winter and spring months. In the febrile affections
of adults broncho-pneumonia is not very common. Thus in typhoid fever
it is not so frequent as lobar pneumonia, though isolated areas of consoli-
dation at the bases are by no means rare in protracted cases of this disease.
In old people it is an extremely common affection, following debilitating
causes of any sort, and supervening in the course of chronic Bright's dis-
ease and various acute and chronic maladies.
2. In the second division of this affection are embraced the cases of
so-called aspiration or deglutition pneumonia. Whenever the sensitive-
ness of the larynx is benumbed, as in the coma of apoplexy or uraemia,
minute particles of food or drink are allowed to pass the rwia^ and, reach-
ing finally the smaller tubes, excite an intense inflammation similar to the
vagus pneumonia which follows the section of the pneumogastrics in the
dog. Cases are very common after operations about the mouth and nose,
after tracheotom}^, and in cancer of the larynx and oesophagus. The
aspirated particles in some instances induce such an intense broncho-
pneumonia that suppuration or even gangrene supervenes.
3. The most common and fatal form of broncho-pneumonia is that
excited by the tubercle bacillus, which has already been considered.
Among general predisposing causes may be mentioned age. As just
noted, it is prone to attack infants, and a majority of cases of pneumonia
in children under five years of age are of this form. At the opposite
extreme of life it is also common, particularly in association with various
debilitating circumstances and chronic diseases incident to the old. In
children rickets and diarrhoea are marked predisposing causes, and bron-
cho-pneumonia is one of the most frequent post-mortem-room lesions in
infants' homes and foundling asylums. The disease prevails more exten-
sively among the poorer classes, because their children are of necessity
more exposed and cannot have the needful care and nursing, particularly
after eruptive fevers.
Morbid Anatomy. — In the lungs of a child dead of broncho-
pneumonia, after measles or diphtheria, the appearances are very charac-
teristic. On the pleural surfaces, particularly toward the base, are seen
depressed bluish or blue-brown areas of collapse, between which the lung
tissue is of a lighter color. Here and there are projecting portions over
which the pleura may be slightly turbid or granular. The lung is fuller
and firmer than normal, and, though in great part crepitant, there can be
felt in places throughout the substance solid, nodular bodies. The dark
depressed areas may be isolated or a large section of one lobe may be in
the condition of collapse or atelectasis. Gradual inflation by a blow-pipe
inserted in the bronchus will distend a great majority of these collapsed
areas. On section, the general surface has a dark reddish color and usu-
538 DISEASES OF THE RESPIRATORY SYSTEM.
ally drips blood. Projecting above the level of the section are lighter red
or reddish-gray areas representing the patches of broncho-pneumonia.
These may be isolated and separated from each other by tracts of unin-
flamed tissue or they may be in groups or the greater part of a lobe may
be involved. Study of a favorable section of an isolated patch shows : (a)
A dilated central bronchiole full of tenacious purulent mucus. A fortu-
nate section parallel to the long axis may show a racemose arrangement —
the alveolar j^assages full of muco-pus. (b) Surrounding the bronchus
for from 3 to 5 mm. or even more is an area of grayish-red consolidation,
usually elevated above the surface and firm to the touch. Unlike the
consolidation of lobar pneumonia, it may present a perfectly smooth sur-
face, though in some instances it is distinctly granular. In a late stage of
the disease small grayish- white points may be seen, which on pressure may
be squeezed out as purulent droplets. A section in the axis of the lobule
may present a somewhat grape-like arrangement, the stalk and stems
representing the bronchioles and alveolar passages filled with a yellowish
or grayish-white pas, while surrounding them is a reddish -brown hepatized
tissue, (c) In the immediate neighborhood of this peribronchial inflam-
mation the tissue is dark in color, smooth, airless, at a somewhat lower
level than the hepatized portion, and differs distinctly in color and ap-
pearance from the other portions of the lung. This is the condition to
which the term splenization has been given. It really represents a tissue
in the early stage of inflammation, and it perhaps w^ould be as well to give
up the use of this term and also that of carnification^ which is only a more
advanced stage. The condition of collapse probably always precedes this,
and it is difficult in some instances to tell the difference, as one shades into
the other. In fact, collapse, splenization, and carnification may be said in
broncho-pneumonia to be steps preliminary to the condition of actual
hepatization.
While, in many cases, the areas of broncho-pneumonia present a red-
dish-brown color and are indistinctly granular, in others, particularly
in adults, the nodules may resemble more closely gray hepatization and
the air-cells are filled with a grayish, muco-purulent material. Minute
haemorrhages are sometimes seen in the neighborhood of the inflamed
areas or on the pleural surfaces. Emphysema is commonly seen at the
anterior borders and upper portions of the lung or in lobules adjacent to
the inflamed ones. In many cases following diphtheria and measles the
process is so extensive that the greater part of a lobe is involved, and it
looks like a case of lobar hepatization. It has not, however, the uniform-
ity of this affection and collapsed dark strands may be seen between ex-
tensive areas of hepatized tissue.
Practically, in the morbid anatomy of broncho-pneumonia in children
we may recognize three groups of cases: (1) Those in which the bron-
chitis and bronchiolitis are most marked and in which there may be no
definite consolidation and yet on microscopical examination many of the
RIIONCIIO-PNEUMONIA. 539
alveolar passages and adjacent air-cells appear filled with inflammatory
products. (2) The disseminated broncho-pneumonia, in which there are
scattered areas of peribronchial hepatization with patches of collapse,
while a considerable proportion of the lobe is still crepitant. This is by
far the most common condition. (3) Pseud o-lobar form, in which the
greater portion of the lobe is consolidated, but not uniformly, for inter-
vening strands of dark congested lung tissue separate the groups of hepa-
tized lobules.
In the secondary broncho-pneumonia of adults, it is generally the dis-
seminated form which is seen.
Microscopically, a cross section of a small broncho-pneumonic focus
shows the following changes : In the centre is a bronchus filled with a
plug of exudation, consisting of leucocytes and swollen epithelium. Sec-
tion in the long axis may show irregular dilatations of the tube. The
bronchial wall is swollen and infiltrated with cells. Under a low power it
is readily seen that the air-cells next the bronchus are most densely filled,
while toward the periphery of the focus the alveolar exudation becomes
less. The contents of the air-cells are made up of leucocytes and swollen
endothelial cells in varying proportion. Eed corpuscles are not often
present and a fibrin network is rarely seen, though it may be present in
some alveoli. In the swollen walls are seen distended capillaries and
numerous leucocytes. As Delafield has pointed out, the interstitial in-
flammation of the bronchi and alveolar walls is a special feature of
broncho-pneumonia which distinguishes it from the ordinary croupous
form.
The histological changes in the aspiration or deglutition broncho-
pneumonia differ from the ordinary post-febrile form in a more intense
infiltration of the air-cells with leucocytes, producing suppuration and
foci of softening, and even tending to gangrene.
Broncho-pneumonia may terminate (1) in resolution^ which when it
once begins goes on more rapidly than in fibrinous pneumonia. Broncho-
pneumonia of the apices, in a child, persisting for three or more weeks,
particularly if it follows measles or diphtheria, is often tuberculous. In
these instances, when resolution is supposed to be delayed, caseation has
in reality taken place. (2) In Huppuration^ which is rarely seen apart
from the aspiration and deglutition forms, in which it is extremely com-
mon. (3) In gangrene^ which occurs under the same conditions. (4) In
fibroid changes — chronic hroncho-pneumojiia — a rare termination in the
simple, a common sequence of the tuberculous disease. Formerly it was
thought that one of the most common changes in bronch6-pneumonia,
particularly in children, was caseation ; but this is really a tuberculous
process, the natural termination of an originally specific broncho-pneu-
monia. It is of course quite possible that a broncho-pneumonia, simple
in its oi'igin, may subsequently be the seat of infection by the bacillus
tuberculosis.
'66
540 DISEASES OP THE RESPIRATORY SYSTEM.
Symptoms. — Much confusion has arisen from the description of
capillary bronchitis as a separate affection, whereas it is only a part,
though a primary and important one, of broncho-pneumonia. At the
outset it nuiy be said that if in convalescence from measles or in whoop-
ing-cough a child has an accession of fever with cough, rapid pulse, and
rapid breathing, and if, on auscultation, fine rales are heard at the bases,
or widely spread throughout the lungs, even though neither consolidation
nor blowing breathing can be detected, the diagnosis of broncho-pneu-
monia may safely be made. I have never seen in a fatal case after diph-
theria or measles a capillary bronchitis as the sole lesion. The onset is
rarely sudden, or with a distinct chill ; but after a day or so of indis-
position the child gets feverish and begins to cough and to get short of
breath. The fever is extremely variable ; a range of from 102° to 104° is
common. The skin is very dry and pungent. The cough is hard, dis-
tressing, and may be painful. Dyspnoea gradually becomes a prominent
feature. Expiration may be jerky and grunting. The respirations may
rise as high as 60 or even 80 in the minute. Within the first forty-eight
hours the percussion resonance is not impaired ; the note, indeed, may be
very full at the anterior borders of the lungs. On auscultation, many
rdles are heard, chiefly the fine subcrepitant variety, with sibilant rhonchi.
There may really be no signs indicating that the parenchyma of the lung is
involved, and yet even at this early stage, within forty-eight hours of the
onset of the pulmonary symptoms, I have repeatedly, after diphtheria,
found scattered nodules of lobular hepatization. Northrup,* in his thor-
ough article on the subject, notes a case in which death occurred within
the first twenty-four hours, and, in addition to the extensive involvement
of the smaller bronchi, the intralobular tissue also was involved in places.
The dyspnoea is constant and progressive and soon signs of deficient aera-
tion of the blood are noted. The face becomes a little suffused and the
finger-tips bluish. The child has an anxious expression and gradually
enters upon the most distressing stage of asphyxia. At first the urgency
of the symptoms is marked, but soon the benumbing influence of the car-
bon dioxide on the nerve-centres is seen and the child no longer makes
strenuous efforts to breathe. The cough subsides and, with a gradual
increase in lividity and a drowsy restlessness, the right ventricle becomes
more and more distended, the bronchial rdles become more liquid as the
tubes fill with mucus, and death occurs from heart paralysis. These are
the symptoms of a severe case of broncho-pneumonia, or what the older
writers called suffocative catarrh.
The phyHcal signs may at first be those of capillary bronchitis, as in-
dicated by the absence of dulness, the presence of fine subcrepitant and
whistling rAles. In many cases death takes place before any definite pneu-
monic signs are detected. When these exist they are much more frequent
* Reference Handbook of the Medical Sciences, art. Broncho-Pneumonia.
BRONCIIO-PNEUMONIA. 541
at the bases, where there may be areas of impaired resonance or even of
positive dulness. When numerous foci involve the greater part of a lobe
the breathing may become tubular, but in the scattered patches of ordi-
nary broncho-pneumonia, following the fevers, the breathing is more com-
monly harsh than blowing. In grave cases there is retraction of the base
of the sternum and of the lower costal cartilages during inspiration, point-
ing to deficient lung expansion.
Diagnosis. — With lobar pneumonia it may readily be confounded if
the areas of consolidation are large and merged together. It is to be re-
membered that broncho-pneumonia occurs chiefly in children under five
years of age, whereas lobar pneumonia in children is much more common
between the ages of five and fifteen. No writer has so clearly brought
out the difference between pneumonia at these periods as Gerhard,* of
Philadelphia, whose papers on this subject, though published nearly sixty
years ago, have the freshness and accuracy which characterize all the writ-
ings of that eminent physician. Holt has recently brought forward figures
to show that lobar pneumonia is not infrequent in infants under two years
of age. The mode of onset is essentially different in the two affections,
the one developing insidiously in the course or at the conclusion of an-
other disease, the other setting in abruptly in a child in good health. In
lobar pneumonia the disease is almost always unilateral, in broncho-pneu-
monia bilateral. The chief trouble arises in cases of broncho-pneumo-
nia, which by aggregation of the foci involves the greater part of one lobe.
Here the difficulty is very great, and the physical signs may be practically
identical, but in a broncho-pneumonia it is much more likely that a lesion
will be found on the other side. The course of the two affections is very
unlike ; the lobar pneumonia in children terminates on the eighth or
tenth day with abruptness, as in adults.
A still more difficult question to decide is whether an existing broncho-
pneumonia is simple or tuberculous. In many instances the decision can-
not be made, as the circumstances under which the disease occurs, the
mode of onset, and the physical signs may be identical. It has often been
my experience that a case has been sent down from the children's ward to
the dead-house with the diagnosis of post-febrile broncho-pneumonia in
which there was no suspicion of the existence of tuberculosis ; but on sec-
tion there were found tuberculous bronchial glands and scattered areas of
broncho-pneumonia, some of which were distinctly caseous, while others
showed signs of softening. I have already spoken fully of this in the
section on tuberculosis, but it is well to emphasize the fact that there
are many cases of broncho-pneumonia in children which time alone en-
ables us to distinguish from tuberculosis. The existence of extensive dis-
ease at the apices or central regions is a suggestive indication, and signs
of softening may be detected. In the vomited matter, which is brought
* American Journal of tho Medical Sciences, vols, xiv and xv.
542 DISEASES OF THE RESPIRATORY SYSTEM.
up after severe spells of coughing, sputum may be picked out and elastic
tissue and bacilli detected.
It is a superfluous refinement to make a diagnosis between capillary
bronchitis and catarrhal pneumonia, for the two conditions are part and
parcel of the same disease. In simple bronchitis involving the larger
tubes urgent dyspnoea and pulmonary distress are rarely present and the
rales are coarser and more sibilant. It must not be forgotten that, as in
lobar pneumonia, cerebral symptoms may mask the true nature of the
disease, and may even lead to the diagnosis of meningitis. I recall more
than one instance in which it could not be satisfactorily determined
whether the infant had tuberculous meningitis or a cerebral complica-
tion of an acute pulmonary affection.
Prognosis. — In children enfeebled by constitutional disease and pro-
longed fevers broncl.o-pneumonia is terribly fatal, but in cases coming
on in connection with whooping-cough or after measles recovery may
take place in the most desperate cases. It is in this disease that the truth
of the old maxim is shown — " Never despair of a sick child." The death-
rate in children under five has been variously estimated at from thirty
to fifty per cent. After diphtheria and measles thin, wiry children seem
to stand broncho-pneumonia much better than fat, flabby ones. In adults
the aspiration or deglutition pneumonia is a very fatal disease.
Prophylaxis. — Much can be done to reduce the probability of attack
after febrile affections. Thus, in the convalescence from measles and
whooping-cough, it is very important that the child should not be exposed
to cold, particularly at night, when the temperature of the room naturally
falls. In a nocturnal visit to the nursery — sometimes, too, I am sorry to
say, to a children's hospital — how often one sees children almost naked,
having kicked aside the bedclothes and having the night-clothes up about
the arms ! The use of light flannel " combinations " obviates this noctur-
nal chill, which is, I am sure, an important factor in the colds and pulmo-
nary affections of young children, both in private houses and in institu-
tions. The catarrhal troubles of the nose and throat should be carefully
attended to, and during fevers the mouth should be washed two or three
times a day with an antiseptic solution.
Treatment.— The frequency and the seriousness of broncho-pneu-
monia render it a disease which taxes to the utmost the resources of the
practitioner. There is no acute pulmonary affection over which he at
times so greatly despairs. On the other hand, there is not one in wliich
he will be more gratified in saving cases which have seemed past all succor.
The general arrangements should receive special attention. The room
should be kept at an even temperature — about 65° to 68° — and the air
should be kept moist with vapor.
At the outset the bowels should be opened by a mild purge, either
castor oil or small doses of calomel, one twelfth to one sixth of a grain
hourly until a movement is obtained, and care should be taken throughout
BRONCIIO-PNEUMONIA. 543
the attack to secure a daily movement, l^he common saline fever mixture
of citrate of potash, liquor ammoniae acetatis, and aromatic spirits of am-
monia may be given every two or three hours. If the disease comes on
abruptly with high fever, minim or minim and a half doses of the tincture
of aconite may be given with it. The pain, the distressing symptoms, and
the incessant cough often demand opium, which must of course be used
with care and judgment in the case of young children, but which is cer-
tainly not contra-indicated and may be usefully given in the form of
Dover's powder. Blisters are now rarely if ever employed, and even the
jacket poultice has gone out of fashion. For the latter, however, I con-
fess to a strong prejudice, and when lightly made and frequently changed
it undoubtedly gives great relief. Much more commonly we now see,
both in private and in hospital practice, the jacket of cotton-batting.
Ice-poultices to the chest I have seen used apparently with great bene-
fit, and they are warmly recommended by many German physicians as
well as by Goodhart and others in England. The diet should consist
of milk, broths, and egg albumen. Milk often curds and is disagreeable.
Egg-white is particularly suitable and very acceptable when given in cold
water with a little sugar. It forms, indeed, an excellent medium for the ad-
ministration of the stimulants. If the pulse shows signs of failing, it is best
to begin early with brandy. As in all febrile affections of children, cold
water should be constantly at the bedside, and the child should be encour-
aged to drink freely. With these measures, in many cases the disease pro-
gresses to a favorable termination, but too often other and more serious
symptoms arise. Cough becomes more distressing, dyspnoea increases,
the ominous rattling of the mucus can be heard in the tubes, the child's
color is not so good, and there is greater restlessness. Under these cir-
cumstances stimulant expectorants — ammonia, squills, and senega — should
be given. Together they make a very disagreeable dose for a young child,
particularly with the carbonate of ammonia. The aromatic spirits of am-
monia is somewhat better. If the carbonate is employed, it must be given
in small doses, not more than a grain to an infant of eighteen months. If
the child has increasing difficulty in getting up the mucus, an emetic
should be given — either the wine of ipecac or, if necessary, tartar emetic.
There is no necessity, however, to keep the child constantly nauseated.
Enough should be given to cause prompt emesis, and the benefit results in
the expulsion of mucus from the larger tubes. In this stage, too, strych-
nine is undoubtedly helpful in stimulating the depressed respiratory cen-
tre. With commencing cyanosis, inhalations of oxygen may be employed,
sometimes with great benefit.
With rapid failure of the heart, loud mucous rattles in the throat, and
increasing lividity, every measure should be used to arouse the child and
excite coughing. Alternate douches of hot and cold water, electricity,
whif;h I have seen appli(;d with good results at Wiederhofer's clinic in
Vi(;nna, and hypodermic injections of ether may be tried. For the reduc-
544 DISEASES OF THE RESPIRATORY SYSTEM.
tiou of temperature, particularly if cerebral symptoms arc prominent, there
is nothing so satisfactory as the wet pack or the cold bath. In the case
of children, when the latter is used it should be graduated, beginning with
a temperature which is pleasantly warm and gradually reducing it to 75°
or 80°. Even when the temperature is not high, the cerebral symptoms
are greatly relieved by the bath or the pack.
V. EMPHYSEMA.
Eupture of superficial vesicles may produce pneumothorax. In the
case of deep-seated alveoli the air escapes into the interlobular connective
tissue and causes a condition comparable to ordinary subcutaneous emphy-
sema. It is not a very serious condition and rarely produces symptoms.
It usually results from violent expiratory efforts, as in w^hooping-cough.
The air-bubbles escape into the interlobular tissue, in which they look
like little rows of beads, and when extensive, the lobules are distinctly out-
lined by them (interstitial emphysema). There may be large bullae be-
neath the pleura. A very rare event is the rupture close to the root of
the lung and the passage of air along the trachea into the subcutaneous
tissues of the neck.
The condition in which the infundibular passages and the alveoli are
dilated is called vesicular empliysema.
A practical division may be made into compensatory, hypertrophic,
and atrophic forms.
I. Compensatory Emphysema.
Whenever a region of the lung does not expand fully in inspiration,
either another portion of the lung must expand or the chest wall sink in
order to occupy the space. The former almost invariably occurs. We
have already mentioned that in broncho-pneumonia there is a vicarious
distention of the air-vesicles in the adjacent healthy lobules, and the same
happens in the neighborhood of tuberculous areas and cicatrices. In gen-
eral pleural adhesions there is often compensatory emphysema, particu-
larly at the anterior margins of the lung. The most advanced example of
this form is seen in cirrhosis, when the unaffected lung increases greatly
in size, owing to distention of the air-vesicles. A similar though less
marked condition is seen in extensive pleurisy with effusion and in pneu-
mothorax.
At first, this distention of the air-vesicles is a simple physiological
process and the alveolar walls are stretched but not atrophied. Ulti-
mately, however, in many cases they waste and the contiguous air-cells
fuse, producing true emphysema.
EMPHYSEMA. 545
II. Hypertiiopjiic Emphysema.
This form, also known as substantive or idiopathic emphysema, is a
well-marked clinical affection, characterized by enlargement of the
lungs, due to distention of the air-cells and atrophy of their walls, and
clinically by imperfect aeration of the blood and more or less marked
dyspnoea.
Etiology. — Emphysema is the result of persistently high intra-
alveolar tension acting upon a congenitally weak lung tissue. If the
mechanical views which have prevailed so long as to its origin were true,
the disease would certainly be much more common ; since violent respira-
tory efforts, believed to be the essential factor, are performed by a majority
of the working classes. Strongly in favor of the view that the nutritive
change in the air-cells is the primary factor is the markedly hereditary
character of the disease and the frequency with which it starts early in
life. These are two points upon which scarcely sufficient stress has been
laid. To James Jackson, Jr., of Boston, we owe the first observations
on the hereditary character of emphysema. Working under Louis's
directions, he found that in 18 out of 28 cases one or both parents were
affected.
I have been impressed by the frequency of the condition in children,
and the number of cases in which on inquiry sym.ptoms pointing to the
occurrence of the disease in childhood can be obtained. It may develop,
too, in several members of the same family. We are still ignorant as to
the nature of this congenital pulmonary weakness. Cohnheim thinks it
probably due to a defect in the development of the elastic-tissue fibres, a
statement Avhich is borne out by Eppinger's observations.
Heightened pressure within the air-cells may be due to forcible in-
spiration or expiration. Much discussion has taken place as to the part
played by these two acts in the production of the disease. The inspiratory
theory was advanced by Laennec and subsequently modified by Gairdner,
who held that in the chronic bronchitis areas of collapse were induced,
and compensatory distention took place in the adjacent lobules. This
unquestionably does occur in the vicarious or compensatory emphysema,
but it probably is not a factor of much moment in the form now under
consideration. The expiratory theory, which was supported by Mendel-
sohn and Jenner, accounts for the condition in a much more satisfactory
way. In all straining efforts and violent attacks of coughing, the glottis
is closed and the chest walls are strongly compressed by muscular efforts,
80 that the strain is thrown upon those parts of the lung least protected,
as the apices and the anterior margins, in which we always find the
emphysema most advanced. The sternum and costal cartilages gradually
yield to tlie heightened intrathoracic pressure and are. in advanced
cases, pushed forward, giving the characteristic rotundity to the thorax.
As mentioned, the cartilages gradually become calcified. One theory of
546 DISEASES OP THE RESPIRATORY SYSTEM.
the disease is that there is a gradual enlargement of the thorax and the
lungs increase in volume to fill up the space.
Of other etiological factors occupation is the most important. The
disease is met with in players on wind instruments, in glass-blowers, and
in occupations necessitating heavy lifting or straining. Whooping-cough
and bronchitis play an important role^ not so much in the changes which
they induce in the bronchi as in consequence of the prolonged attacks of
coughing.
Morbid Anatomy. — The thorax is capacious, usually barrel-shaped,
and the cartilages are calcified. On removal of the sternum, the anterior
mediastinum is found completely occupied by the edges of the lungs, and
the pericardial sac may not be visible. The organs are very large and
have lost their elasticity, so that they do not collapse either in the thorax
or when placed on the table. The pleura is pale and there is often an
absence of pigment, sometimes in patches, termed by Virchow albinism of
the lung. To the touch they have a peculiar, downy, feathery feel, and
pit readily on pressure. This is one of the most marked features. Be-
neath the pleura greatly enlarged air-vesicles may be readily seen. They
vary in size from -J to 3 mm., and irregular bullae, the size of a walnut
or larger, may project from the free margins. The best idea of the
extreme rarefaction of the tissue is obtained from sections of a lung dis-
tended and dried. At the anterior margins the structure may form an
irregular series of air-chambers, resembling the frog's lung. On careful
inspection with the hand-lens, remnants of the interlobular septa or even
of the alveoli may be seen on these large emphysematous vesicles. Though
general throughout the organs, the distention is more marked, as a rule,
at the anterior margins, and is often specially developed at the inner sur-
face of the lobe near the root, where in extreme cases air-spaces as large
as an egg may sometimes be found. Microscoj)ically there is seen atrophy
of the alveolar walls, by which is produced the coalescence of neighboring
air-cells. In this process the capillary network disappears before the
walls are completely atrophied. The loss of the elastic tissue is a special
feature. It is stated, indeed, that in certain cases there is a congenital
defect in the development of this tissue. The epithelium of the air-cells
undergoes a fatty change, but the large distended air-spaces retain a pave-
ment layer.
The bronchi in emphysema show important changes. In the larger
tubes the mucous membrane may be rough and thickened from chronic
bronchitis ; often the longitudinal lines of submucous elastic tissue stand
out prominently. In the advanced cases many of the smaller tubes are
dilated, particularly when, in addition to emphysema, there are peribron-
chial fibroid changes. Bronchiectasis is not, however, an invariable ac-
companiment of emphysema, but, as Laennec remarks, it is difficult to
understand why it is not more common. Of associated morbid changes
the most important are found in the heart. The right chambers are
EMPHYSEMA. 547
dilated and liypertrophied, the tricuspid orifice is large, and the valve
segments are often thickened at the edges. In advanced cases the cardiac
hypertrophy is general. The pulmonary artery and its branches may ho
wide and show marked atheromatous changes.
The changes in the other organs are those commonly associated with
prolonged venous congestion.
Symptoms. — The disease may be tolerably advanced before any
special symptoms develop. A child, for instance, may be somewhat short
of breath on going up-stairs or may be unable to run and play as other
children without great discomfort ; or, perhaps, has attacks of slight
lividity. Doubtless much depends upon the completeness of cardiac com-
pensation. When this is perfect, there may be no special interruption of
the pulmonary circulation and, except in violent exertion, there is no
interference with the aeration of the blood. In well-developed cases the
following are the most important symptoms : Dyspncea^ which may be
felt only on slight exertion, or may be persistent, and aggravated by in-
tercurrent attacks of bronchitis. The respirations are often harsh and
wheezy, and expiration is distinctly prolonged.
Cyanosis of an extreme grade is more common in emphysema than in
other affections with the exception of congenital heart-disease. So far as I
know it is the only disease in which a patient may be able to go about and
even to walk into the hospital or consulting-room with a lividity of start-
ling intensity. The contrast between the extreme cyanosis and the com-
parative comfort of the patient is very striking. In other affections of
the heart and lungs associated with a similar degree of cyanosis the pa-
tient is invariably in bed and usually in a state of orthopncea.
Broncldtis with associated cough is a frequent symptom and often
the direct cause of the pulmonary distress. The contrast between emphy-
sematous patients in the winter and summer is marked in this respect. In
the latter they may be comfortable and able to attend to their work, but
with the cold and changeable weatlxer they are laid up with attacks of
bronchitis. Finally, in fact, the two conditions become inseparable and
the patient has persistently more or less cough. Tlie acute bronchitis
may produce attacks not unlike asthma. In some instances this is true
spasmodic astlima, with which emphysema is frequently associated.
As age advances and with successive attacks of bronchitis the condi-
tion gets slowly worse. In liospital practice it is common to admit pa-
tients over sixty witli well-marked signs of advanced emphysema. Tlie
affection can generally be told at a glance — the rounded shoulders, barrel
chest, the tliin yet oftentimes muscular form, and sometimes, I tliiuk, a
very characteristic facial expression.
'J'here is another group, liowever, of younger patients from twenty-five
to forty years of age who winter after winter have attacks of intense cya-
nosis in consequence of an aggravated bronchial catarrli. On incjuiry wo
find that these patients have been short-breatlied from infancy, and they
548 DISEASES OF THE RESPIRATORY SYSTEM.
belong, I believe, to a category in which there has been a primary defect
of structure in the lung tissue.
Physical Signs. — Inspection. — The thorax is markedly altered in shape ;
the antero-posterior diameter is increased and may be even greater than
the lateral, so that the chest is barrel-shaped. The appearance is some-
what as if the chest was in a permanent inspiratory position. The ster-
num and costal cartilages are prominent. The lower zone of the thorax
looks large and the intercostal spaces are much widened, particularly in
the hypochondriac regions. The sternal fossa is deep, the clavicles stand
out with great prominence, and the neck looks shortened from the eleva-
tion of the thorax and the sternum. A zone of dilated venules may be
seen along the line of attachment of the diaphragm. Though this is
common in em_physema, it is by no means peculiar to it. Andrew, of
Bartholomew's Hospital, and, according to Duckworth, Laycock have
called attention to it. This network in the lower thoracic region, just
above the costal margin and following its curves, is a well-marked feature
in many persons, and is seen not only in emphysema, but in many cases
of hepatic trouble.
Behind, the curve of the spine is increased and the back is remarkably
rounded, so that the scapulae seem to be almost horizontal. Mensuration
shows the rounded form of the chest ; the antero-posterior diameter may
exceed the transverse. The respiratory movements, which may look ener-
getic and forcible, exercise little or no influence. The chest does not
expand, but there is a general elevation. The inspiratory effort is short
and quick ; the expiratory movement is prolonged. There may be retrac-
tion instead of distention in the upper abdominal region during inspira-
tion, and there is sometimes seen a transverse curve crossing the abdomen
at the level of the twelfth rib. The apex beat of the heart is not visible,
and there is usually marked pulsation in the epigastric region. The cer-
vical veins stand out prominently and may pulsate.
Palijation. — The vocal fremitus is somewhat enfeebled but not lost.
The apex beat can rarely be felt. There is a marked shock in the lower
sternal region and very distinct pulsation in the epigastrium. Percussion
gives greatly increased resonance, full and drum-like — what is sometimes
called hyperresonance. The note is not often distinctly tympanitic in
quality. The percussion note is greatly extended, the heart dulness may
be obliterated, the upper limit of liver dulness is greatly lowered, and the
resonance may extend to the costal margin. Behind, a clear percussion
note extends to a much lower level than normal. The level of splenic
dulness, too, may be lowered.
On ausci(ltatio7i the breath-sounds are usually enfeebled and may be
masked by bronchitic rales. The most characteristic feature is the pro-
longation of the expiration, and the normal ratio may be reversed — 4 to 1
instead of 1 to 4. It is often wheezy and harsh and associated with coarse
rdles and sibilant rhonchi. It is said that in interstitial emphysema there
EMPnYSEMA. 549
may be a friction sound heard not unlike that of pleurisy. As already
noted, the cardiac impulse may be barely felt in the lower sternal region.
The heart-sounds are usually clear ; but in advanced cases, when there is
marked cyanosis, a tricuspid regurgitant murmur may be heard. Accent-
uation of the pulmonary second sound is present.
The course of the disease is slow but progressive, the recurring attacks
of bronchitis aggravating the condition. Death may occur from intercur-
rent pneumonia, either lobar or lobular, and dropsy may supervene from
cardiac failure. Occasionally death results from overdistention of the
heart, with extreme cyanosis. Duckworth has called attention to fatal
haemorrhage in emphysema. It certainly is not common. In an old em-
physematous patient at the Montreal General Hospital death followed the
erosion of a main branch of the pulmonary artery by an ulcer near the
bifurcation of the trachea.
Treatment. — Practically, the measures mentioned in connection
with bronchitis should be employed. No remedy is known which has any
influence over the progress of the condition itself. Bronchitis is the great
danger of these patients, and therefore when possible they should live in
an equable climate. In consequence of the venous engorgement they are
liable to gastric and intestinal disturbance, and it is particularly important
to keep the bowels regulated and to avoid the flatulency which often seri-
ously aggravates the dyspnoea. Patients who come into the hospital in
a state of urgent dyspnoea and lividity, with great engorgement of the veins,
particularly if they are young and vigorous, should be bled freely. On
more than one occasion I have saved the lives of persons in this condition
by venesection. Inhalation of oxygen may be used and the remedies
given already mentioned in connection with bronchitis. Strychnine will
be found specially useful.
III. Atrophic Emphysema.
This is really a senile change and is called by Sir William Jenner small-
lunged emphysema. It is really a primary atrophy of the lung, coming
on in advanced life, and scarcely constitutes a special affection. It occurs
in " withered-looking old persons " who may perhaps have had a winter
cough and shortness of breath for years. In striking contrast to the essen-
tial or hypertrophic emphysema, the chest in this form is small. The ribs
are obliquely placed, the decrease in the diameter being due to greatly in-
creased obliquity in the position of the ribs. The thoracic muscles are
usually atrophied. In advanced cases of this affection the lung presents a
remarkable appearance, being converted into a series of large vesicles, on
the walls of which the remnants of air-cells may be seen. It is a condition
for which nothing can be done.
550 DISEASES OF THE RESPIRATORY SYSTEM.
VI. GANGRENE OF THE LUNG.
Etiology. — Gangrene of the lung is not an affection per se, but oc-
curs in a variety of conditions when necrotic areas undergo putrefaction.
It is not easy to say why sphacelus should occur in one case and not in
another, as the germs of putrefaction are always in the air-passages, and
yet necrotic territories rarely become gangrenous. Total obstruction of a
pulmonary artery, as a rule, causes infarction, and the area shut off does
not often, though it may, sphacelate. Another factor would seem to be
necessary — probably a lowered tissue resistance, the result of general or
local causes. It is met with (1) as a sequence of lobar pneumonia. This
rarely occurs in a previously healthy person — more commonly in the de-
bilitated or in the diabetic subject. (2) Gangrene is very prone to follow
the aspiration pneumonia, since the foreign particles rapidly undergo
putrefactive changes. Of a similar nature are the cases of gangrene due
to perforation of cancer of the oesophagus into the lung or into a bronchus.
(3) The putrid contents of a bronchiectatic, more commonly of a tuber-
culous, cavity may excite gangrene in the neighboring tissues. The press-
ure bronchiectasis following aneurism or tumor may lead to extensive
sloughing. (4) Gangrene may follow simple embolism of the pulmonary
artery. More commonly, however, the embolus is derived from a part
which is mortified or comes from a focus of bone disease. Lastly, gan-
grene of the lung may occur in conditions of debility during convales-
cence from protracted fever — occasionally, indeed, without our being able
to assign any reasonable cause.
Morbid Anatomy. — Laennec, who first accurately described pul-
monary gangrene, recognized a diffuse and a circumscribed form. The
former, though rare, is sometimes seen in connection with pneumonia,
more rarely after obliteration of a large branch of the pulmonary artery.
It may involve the greater part of a lobe, and the lung tissue is converted
into a horribly offensive greenish-black mass, torn and ragged in the centre.
In the circumscribed form there is well-marked limitation between the
gangrenous area and the surrounding tissue. The focus may be single or
there may be two or more. The lower lobe is more commonly affected
than the upper, and the peripheral more than the central portion of the
lung. A gangrenous area is at first uniformly greenish brown in color ;
but softening rapidly takes place with the formation of a cavity Avith
shreddy, irregular walls and a greenish, offensive fluid. The lung tissue
in the immediate neighborhood shows a zone of deep congestion, often
consolidation, and outside this an intense oedema. In the embolic cases
the plugged artery can sometimes be found. When rapidly extending,
vessels may be opened and violent hemorrhage ensue. Perforation of the
pleura is not uncommon. The irritating decomposing material usually
excites the most intense bronchitis. Embolic processes are not infrequent.
There is a remarkable association in some cases between circumscribed
GANGRENE OF THE LUNG. 551
gangrene of the lung and abscess of the brain. I have seen two such
cases. One of these, a young man, an Arab, was brought to the Uni-
versity Hospital, almost exsanguine from pulmonary hsemorrhagc. He
gradually recovered. There were very limited signs in the middle lobe
of the right lung, which persisted, but no bacilli were found. There was
no fetor of the breath. AVeeks afterward he developed severe headache,
and in a few days became comatose and died. There was a circumscribed
area of healing gangrene at the margin of the lung with great increase of
fibrous tissue about it. The artery going to this somewhat wedge-shaped
area was obliterated. The contents of the encapsulated cavity were very
fetid. There was a large limited abscess in the parieto-temporal region
on the right side.
Symptoms and Course. — Usually definite symptoms of local pul-
monary disease precede the characteristic features of gangrene. These,
of course, are very varied, depending on the nature of the trouble. The
sputum is very characteristic. It is intensely fetid — usually profuse —
and, if expectorated into a conical glass, sejoarates into three layers — a
greenish-brown, heavy sediment ; an intervening thin liquid, which some-
times has a greenish or a brownish tint ; and, on top, a thick, frothy layer.
Spread on a glass plate, the shreddy fragments of lung tissue can readily
be picked out. Microscopically, elastic fibres are found in abundance,
with granular matter, pigment grains, fatty crystals, bacteria, and lepto-
thrix. It is stated that elastic tissue is sometimes absent, but I have never
met with such an instance. The peculiar plugs of sputum which occur
in bronchiectasy are not found. Blood is often present, and, as a rule, is
much altered. The sputum has, in a majority of the cases, an intensely
fetid odor, which is communicated to the breath and may permeate the
entire room. It is much more oifensive than in fetid bronchitis or in
abscess of the lung. The fetor is particularly marked when there is free
communication between the gangrenous cavities and the bronchi. On
several occasions I have found, post mortem, localized gangrene, which
had been unsuspected during life, and in which there had been no fetor
of the breath.
The physical signs, when extensive destruction has occurred, are those
of cavity, but the limited circumscribed areas may be difficult to detect.
Bronchitis is always present.
Among the general symptoms may be mentioned fever, usually of
moderate grade ; the pulse is rapid, and very often the constitutional de-
pression is severe. But the only special features indicative of gangrene
are the sputa and the fetor of tlie breath. The patient generally sinks
from exhaustion. Fatal haemorrhage may ensue. I have already men-
tioned a case in which a ha3morrhagc from a circumscribed gangrene
nearly provcul fatal, and I have seen one fatal instance after pneumonia.
Treatm.ent. — The treatment of gangrene is very unsatisfactory. '^I'lie
indications, of course, are to disinfect the gangrenous area, but this is
552 DISEASES OP THE RESPIRATORY SYSTEM.
often impossible. An antiseptic spray of carbolic acid may be employed.
A good plan is for the patient to use over the mouth and nose an inhaler,
which may be charged with a solution of carbolic acid or creosote. If the
signs of cavity are distinct an attempt should be made to cleanse it by
direct injections of an antiseptic solution. If the patient's condition is
good and the gangrenous region can be localized, an attempt should be
made to treat it surgically. Successful cases have been reported. The
general condition of the patient is always such as to demand the greatest
care in the matter of diet and nursing.
VII. ABSCESS OF THE LUNG.
Etiology. — Suppuration occurs in the lung under the following
conditions : (1) As a sequence of inflammation, either lobar or lobular.
Apart from the purulent infiltration this is unquestionably rare, and even
in lobar pneumonia the abscesses are of small size and usually involve, as
Addison remarked, several points at the same time. On the other hand,
abscess formation is extremely frequent in the deglutiticvi and aspiration
forms of lobular pneumonia. After wounds of the neck or operations
upon the throat, in suppurative disease of the nose or larynx, occasionally
even of the ear (Volkmann), infective particles reach the bronchial tubes
by aspiration and excite an intense inflammation which often ends in
suppuration. Cancer of the oesophagus, perforating the root of the lung
or into the bronchi, may produce extensive suppuration. The abscesses
vary in size from a walnut to an orange, and have ragged and irregular
walls, and purulent, sometimes necrotic, contents.
(2) Embolic, so-called metastatic, abscesses, the result of infectious
emboli, are extremely common in a large proportion of all cases of pyaemia.
They may occur in enormous numbers and present very definite char-
acters. As a rule they are superficial, beneath the pleura, and often
wedge-shaped. At first firm, grayish red in color, and surrounded by a
zone of intense hyperaemia, suppuration soon follows with the formation
of a definite abscess. The pleura is usually covered with greenish lymph,
and perforation sometimes takes place with the production of pneumo-
thorax.
(3) Perforation of the lung from without, lodgment of foreign bodies,
and, in the right lung, perforation from abscess of the liver or suppurating
echinococcus cyst are occasional causes of pulmonary abscess.
(4) Suppurative processes play an important part in chronic pulmonary
tuborciilosis, many of the symptoms of which are due to them.
Symptoms. — Abscess following pneumonia is easily recognized by
an aggrjivatioii of the general symptoms and by the physical signs of cav-
ity and the characters of the expectoration. Embolic abscesses cannot
often be recognized, and the local symptoms are generally masked in the
PNEUMONOKONIOSIS. 553
general pyoemic manifestations. The characters of the sputum are of great
importance in determining the presence of abscess. Tlie odor is offensive,
yet it rarely has the horrible fetor of gangrene or of putrid bronchitis.
In the pus fragments of lung tissue .can be seen, and the elastic tissue may
be very abundant. The presence of this with the physical signs rarely
leaves any question as to the nature of the trouble. Embolic cases usually
run a fatal course. Recovery occasionally occurs after pneumonia.
Medicinal treatment is of little avail in abscess of the lung. When
well defined and superficial, an attempt should always be made to open
and drain it. A number of successful cases have already been treated in
this way.
VIII. PNEUMONOKONIOSIS.
Under this term, introduced by Zenker, is embraced those diseases of
the lungs due to the inhalation of dusts in various occupations. They
have received various names, according to the nature of the inhaled
particles — anthracosis^ or coal-miner's disease ; siderosis^ due to the in-
halation of metallic dusts, particularly iron ; chalicosis^ due to the inhala-
tion of mineral dusts, producing the so-called stone-cutter's phthisis, or
the " grinder's rot " of the Sheffield workers.
The dust particles inhaled into the lungs are dealt with extensively by
the ciliated epithelium and by the phagocytes, which exist normally in the
respiratory organs. The ordinary mucous corpuscles take in a large num-
ber of the particles, which fall upon the trachea and main bronchi. The
cilia sweep the mucus out to a point from which it can be expelled by
coughing. It is doubtful if the particles ever reach the air-cells, but the
swollen alveolar cells (in which they are in numbers) probably pick them
up on the way. The mucous and the alveolar cells are the normal
respiratory scavengers. In dwellers in the country, in which the air is
pure, they are able to prevent the access of dust particles to the lung
tissue, so that even in adults these organs present a rosy tint, very
different from the dark, carbonized appearance of the lungs of dwellers in
cities. When the impurities in the air are very abundant, a certain pro-
portion of the dust particles escapes tliese cells and penetrates the mucosa,
reaching the lymph spaces, where they are attacked at once by the cells
of the connective-tissue stroma, which are capable of ingesting and retain-
ing a large quantity In coal-miners, coal-heavers, and others whose
occupations necessitate the constant breathing of a very dusty atmosphere
even these forces are insufficient. Many of the particles enter the lymph
stream and, as Arnold has shown in his beautiful researches, are carried
(1) to the lymph nodules surrounding the bronchi and blood-vessels; (2)
to the interlobular septa beneath the pleura, where they lodge in and
between the tissue elements; and (3) along the larger lymph channels to
the substernal, bronchial and tracheal glands, in which the stroma cells of
554 DISEASES OF THE RESPIRATORY SYSTEM.
the follicular cords dispose of them permanently and prevent them from
entering the general circulation. Occasionally in anthracosis the carbon
grains do reach the general circulation, and the coal dust is found in the
liver and spleen. As Weigert has shown, this occurs when the densely
pigmented bronchial glands closely adhere to the pulmonary veins, through
the walls of which the carbon particles pass to the general circulation.
The lung tissue has a remarkable tolerance for these particles, probably
because a large proportion of them is warehoused, so to speak, in pro-
toplasmic cells. By constant exposure a limit is reached, and there is
brought about a very definite pathological condition, an interstitial sclero-
sis. In coal-miners this may occur in patches, even before the lung tissue
is uniformly infiltrated with the dust. In others it appears only after the
entire organs have become so laden that they are dark in color, and an
ink-like juice flows from the cut surface. The lungs of a miner may be
black throughout and yet show no local lesions and be everywhere
crepitant.
As already mentioned, the particles are deposited in large numbers in
the follicular cords of the tracheal and bronchial glands and of the peri-
bronchial and peri-arterial lymph nodules, and in these they finally excite
proliferation of the connective-tissue elements. It is by no means un-
common to find in persons whose lungs are only moderately carbonized
the bronchial glands sclerosed and hard. In anthracosis the fibroid
changes usually begin in the peri-bronchial lymph tissue, and in the early
stage of the process the sclerosis may be largely confined to these regions.
A Xova Scotian miner, aged thirty-six, died under my care, at the Mont-
real General Hospital, of black small-pox, after an illness of a few days.
In his lungs (externally coal-black) there were round and linear patches
ranging in size from a pea to a hazel-nut, of an intensely black color, air-
less and firm, and surrounded by a crepitant tissue, slate-gray in color.
In the centre of each of these areas was a small bronchus. Many of them
w^ere situated just beneath the pleura, and formed typical examples of
limited fibroid broncho-pneumonia. In addition there is usually thicken-
ing of the alveolar walls, particularly in certain areas. By the gradual
coalescence of these fibroid patches large portions of the lung may be
converted into firrn grayish-black, in the case of the coal-miner — steel-
gray, in the case of the stone-worker — areas of cirrhosis. In the case of a
Cornish miner, aged sixty-three, who died under my care, one of these
fibroid areas measured 18 by 6 cm. and 4-5 cm. in depth.
A second important factor in these cases is chronic bronchitis, which
is present in a large proportion and really causes the chief symptoms. A
third is the occurrence of emphysema, which is almost invariably associ-
ated with long-standing cases of pneumonokoniosis. With the changes so
far described, unless the cirrhotic area is unusually extensive, the case may
present the features of chronic bronchitis with emphysema, but finally
another element comes into play. In the fibroid areas softening occurs,
PNEUMONOKONIOSIS. 555
probably a process of necrosis similar to that by which softening is pro-
duced in fibro-myomata of the uterus. At first these are small and con-
tain a dark liquid. Charcot calls them, as already mentioned, ulceres du
poumon. They rarely attain a large size unless a communication is
formed with the bronchus, in which case they may become converted
into suppurating cavities. The question has been much discussed of
late as to what part the tubercle bacillus plays in these cases of pneu-
monokoniosis with cavity formation. In some instances there is cer-
tainly a tuberculous process ingrafted, but that large excavations may
occur, or in other instances bronchiectasis without the presence of bacillis,
I have convinced myself by the examination of several characteristic spec-
imens.
The siderosis induced by the oxide of iron causes an interstitial pneu-
monia similar to anthracosis. Workers in brass and in bronze are liable
to a similar aifection.
Chalicosis^ due to the deposit of particles of silex and alumina, is
found in the makers of mill-stones, particularly the French mill-stones,
and also in knife and axe grinders and stone-cutters. Anatomically, this
form is characterized by the production of nodules of various sizes, which
are cut with the greatest difficulty and sometimes present a curious gray-
ish, even glittering, crystalloid appearance.
Workers in flax and in cotton, and grain-shovellers are also subject to
these chronic interstitial changes in the lungs. In all these occupations,
as shown by Greenhow, to whose careful studies we owe so much of our
knowledge of these diseases, the condition of the lung may ultimately be
almost identical.
The symptoms do not come on until the patient has worked for a vari-
able number of years in the dusty atmosphere. As a rule there are cough
and failing health for a prolonged period of time before complete disa-
bility. The coincident emphysema is responsible in great part for the
shortness of breath and wheezy condition of these patients. The expec-
toration is usually muco-purulent, often profuse ; in a case of anthra-
cosis, very dark in color — the so-called " black spit " ; in a case of chalicosis
there may be seen under the microscope tlie bright angular particles of
silica.
Even when there are physical signs of cavity tubercle bacilli are not
necessarily, and indeed in my experience they are not usually present. It
is remarkable for how long a time a coal-miner may continue to bring
up sputum laden with coal particles even when there are only signs
of a chronic bronchitis. Many of the particles are contained in the
cells of the alveolar epithelium. In these instances it appears that an
attempt is made by the leucocytes to rid the lungs of some of the carbon
grains.
The diagnosis of the condition is rarely difficult ; the expectoration is
usually characteristic. It must always be borne in mind that chronic
3«
556 DISEASES OF THE RESPIRATORY SYSTEM.
bronchitis and emphysema form essential parts of the process and that in
late stages there may be tuberculous infection.
The treatment of the condition is practically that of chronic bronchitis
and emphysema.
IX. NEW GROWTHS IN THE LUNGS.
Etiology and Morbid Anatomy. — While primary tumors are
rare, secondary growths are not uncommon.
The primary growths of the lung are either encephaloid, scirrhus or
epithelioma. Eecent observations show that the latter is the most com-
mon form. Sarcoma also is occasionally found as a primary growth, and
still more rarely enchondroma.
The secondary growths may be of various forms. Most commonly
they follow tumors in the digestive or genito-urinary organs ; not infre-
quently also tumors of the bone. There may be encephaloid, scirrhus, epi-
thelioma, colloid, melano-sarcoma, enchondroma, or osteoma.
Primary cancer or sarcoma usually involves only one lung. The sec-
ondary growths are distributed in both. The primary growth generally
forms a large mass, which may occupy the greater part of a lung. Occasion-
ally the secondary growths are solitary and confined chiefly to the pleura,
as in a remarkable example which came under my observation, in which the
disease was secondary to a myelo-sarcoma of the wrist. The tumor mass
occupied a large portion of the left side of the thorax. It grew from the
pleura and extended only slightly into the lung, which was compressed
and airless. The metastatic growths are nearly always disseminated.
Occasionally they occupy a large portion of the pulmonary tissue. In a
case of colloid cancer secondary to cancer of the pancreas, I found both
lungs voluminous, heavy, only slightly crepitant, and occupied by circular
translucent masses, varying in size from a pea to a large walnut.
There are numerous accessory lesions in the pulmonary new growths.
There may be pleurisy, either cancerous or sero-fibrinous. The eifusion
may be haemorrhagic, but in 200 cases of cancer, primary or secondary, of
the lungs and pleura analyzed by Moutard-Martin, haemorrhagic effusion
occurred in only twelve per cent. The tracheal and bronchial glands are
usually affected, the cervical glands not infrequently, and occasionally even
the inguinal.
The disease is most common in the middle period of life. The pri-
mary form affects the sexes equally, but secondary cancer is much more
frequent in women than in men. The conditions which predispose to it
are quite unknown. It is a remarkable fact that the workers in the
Schneeberg cobalt mines are very liable to primary cancer of the lungs.
It is stated that in this region a considerable proportion of all deaths in
persons over forty are due to this disease.
NEW GROWTHS IN THE LUNGS. 557
Symptoms. — The clinical features of neoplasms of the lungs are by
no means distinctive, particularly in the case of primary growths. The
patient may, indeed, as noted by Walshe, present no symptoms pointing
to intrathoracic disease. Among the more important symptoms are pain,
particularly when the pleura is involved ; dyspnoea, which is apt to be
paroxysmal when due to pressure upon the trachea ; cough, which may be
dry and painful and accompanied by the expectoration of a dark mucoid
sputum. This so-called prune-juice expectoration, which was present ten
times in eighteen cases of primary cancer of the lung, was thought by
Stokes to be of great diagnostic value.
In many instances there are signs of compression of the large veins,
producing lividity of the face and upper extremities, or occasionally of
only one arm. Compression of the trachea and bronchi may give rise to
urgent dyspnoea. The heart may be pushed over to the opposite side.
The pneumogastric and recurrent laryngeal nerves are occasionally in-
volved in the growth.
Physical Signs. — The patient, according to Walshe, usually lies on the
affected side. On inspection this side may be enlarged and immobile and
the intercostal spaces are obliterated. This is more commonly due to the
effusion than to the growth itself. The external lymph-glands may be
enlarged, particularly the clavicular. The signs, on percussion and aus-
cultation, are varied, depending much upon the presence or absence of
fluid. Signs of consolidation are, of course, present ; the tactile fremitus
is absent and the breath-sounds are usually diminished in intensity. Oc-
casionally there is typical bronchial breathing. Among other symptoms
may be mentioned fever, which is present in a certain number of cases.
Emaciation is not necessarily extreme. The duration of the disease is
from six to eight months. Occasionally the disease runs a very acute
course, as noted by Carswell. Cases are reported in which death occurred
in a month or six weeks, and in one instance— Jaccoud— the patient died
in a week from the onset of the symptoms.
Diagnosis.— In secondary growths this is not difficult. The devel-
opment of pulmonary symptoms within a year or two after the removal of
a cancer of the breast, or after the amputation of a limb for osteo-sarcoma,
or the onset of similar symptoms in connection with cancer of the liver,
or of the uterus, or of the rectum, would be extremely suggestive. In
primary cases the unilateral involvement, the anomalous character of the
physical signs, the occurrence of prune-juice expectoration, the progress-
ive wasting, and the secondary involvement of the cervical glands are the
important points in the diagnosis.
558 DISEASES OF THE RESPIRATORY SYSTEM.
Y. DISEASES OF THE PLEUEA.
I. ACUTE PLEURISY.
Anatomically, the cases may be divided into dry or adhesive pleurisy
and pleurisy with effusion. Another classification is into primary or sec-
ondary forms. According to the course of the disease, a division may be
made into acute and chronic pleurisy, and as it is impossible, at present,
to group the various forms etiologically, this is perhaps the most satisfac-
tory division. The following forms of acute pleurisy may be considered :
I. Fibrinous or Plastic Pleurisy.
In this the pleural membrane is covered by a sheeting of lymph of
variable thickness, which gives it a turbid, granular appearance, or the
fibrin may exist in distinct layers. It occurs (1) as an independent affec-
tion, following cold or exposure. This form of acute plastic pleurisy
witliout fluid exudate is not common in perfectly healthy individuals.
Cases are met with, however, in which the disease sets in with the usual
symptoms of pain in the side and slight fever, and there are the physical
signs of pleurisy as indicated by the friction. After persisting for a few
days, the friction murmur disappears and no exudation occurs. Union
takes place between the membranes, and possibly the pleuritic adhesions
which are found in such a large percentage of all bodies examined after
death originate in these slight fibrinous pleurisies.
Fibrinous pleurisy occurs (2) as a secondary process in acute diseases
of the lung, such as pneumonia, w^hich is always accompanied by a certain
amount of pleurisy, usually of this form. Cancer, abscess, and gangrene
also cause plastic pleurisy when the surface of the lung becomes involved.
This condition is specially associated in a large number of cases with
tuberculosis. Pleural pain, stitch in the side, and a dry cough, with
marked friction sounds on auscultation are the initial phenomena in
many instances of phthisis. The signs are usually basic, but Burney Yeo
has recently called attention to the frequency with which they occur at
the apex.
II. Sero-fibrixous Pleurisy.
In a majority of cases of inflammation of the pleura there is, with the
fibrin, a variable amount of fluid exudate, which produces the condition
known as pleurisy with effusion.
Etiology. — For generations physicians have considered cold the
potent factor in inducing pleurisy. This may be true in many cases, but
modern views of serous inflammations scarcely recognize cold as anything
more than a predisposing agent, which permits the action of various
micro-organisms. We have not yet, however, brought all the acute pleu-
ACUTE PLEURISY. 559
risies into the category of microbic affections, and the fact remains that
pleurisy does follow with great rapidity a sudden wetting or a chill. Of late
years an attempt has been made, particularly by French writers, to show
that the majority of acute pleurisies are tuberculous. In this connection
the following facts maybe admitted: (1) In a limited number of cases
of pleurisy coming on abruptly in healthy persons the disease has been
shown — (a) by post-mortem, in cases of accidental or sudden death, (b) by
the subsequent history — to be tuberculous ; (2) in a larger proportion of
those cases which come on insidiously in persons who have been in failing
health or who are delicate the disease is tuberculous from the outset ; (3)
the acute pleurisy, which occurs as a secondary, often a terminal, event in
chronic affections, such as cirrhosis of the liver, Bright's disease, and
cancer, is very frequently tuberculous. I confess that the more carefully
I have studied the question the larger does the proportion appear to be of
primary pleurisies of tuberculous origin. The subsequent history of cases
of acute pleurisy forces us to conclude that in at least two thirds of the
cases it is a curable affection. This may well be so, according to our pres-
ent ideas of local tuberculous disease. One of the most interesting con-
tributions to this question has been made from the records of Henry I.
Bowditch, of Boston, to whom we are indebted for so many important
contributions to our knowledge of pleurisy.* Of 90 cases of acute pleu-
risy which had been under observation between 1849 and 1879, 32 died
of or had phthisis — a percentage large enough to indicate what an impor-
tant role tuberculosis plays in the etiology of this disease.
Morbid Anatomy. — In sero-fibrinous pleurisy the serous exudate
is abundant and the fibrin is found on the pleural surfaces and scat-
tered through the fluid in the form of flocculi. The proportion of
these constituents varies a great deal. In some instances there is very
little membranous fibrin ; in others it forms thick, creamy layers and ex-
ists in the dependent part of the fluid as whitish, curd-like masses. The
fluid of sero-fibrinous pleurisy is of a citron color, either clear or slightly
turbid, depending on the number of formed elements. In some instances
it has a dark-brown color. The microscopical examination of the fluid
shows leucocytes, occasional swollen cells, which may possibly be derived
from the pleural endothelium, shreds of fibrillated fibrin, and a variable
number of red blood-corpuscles. On boiling, the fluid is found to be rich
in albumen. Sometimes it coagulates spontaneously. Its composition
closely resembles that of blood-serum. Cholesterin, uric acid, and sugar
are occasionally found. The amount of the effusion varies from a half to
four litres.
The lung in acute sero-fibrinous pleurisy is more or less compressed. If
the exudation is limited the lower lobe alone is atelectatic ; but in an exten-
sive effusion which reaches to the clavicle the entire lung will be found
♦ Vincent Y. Bowditch, in Boston Medical and Surgical Journal, 1889.
560 DISEASES OF THE RESPIRATORY SYSTEM.
lying close to the spine, dark and airless, or even bloodless — i. e., car-
nified.
In large exudations the adjacent organs are displaced. In large right-
sided pleurisies the liver is much depressed. Eather varying statements
are made with reference to the position of the heart and as to whether or
not it rotates on its axis. In a number of post-mortems I have carefully
studied its position, both in pneumothorax and in large effusions, and can
speak with some degree of certainty on the following points : (1) Even in
the most extensive left-sided exudation there is no rotation of the apex
of the heart, which in no case was to the right of the mid-sternal line ;
(2) the relative position of the apex and base is usually maintained; in
some instances the apex is lifted, in others the whole heart lies more trans-
versely ; (3) the right chambers of the heart occupy the greater portion of
the front, so that the displacement is rather a definite dislocation of the
mediastinum, with the pericardium, to the right, than any special twisting
of the heart itself ; (4) the kink or twist in the inferior vena cava described
by Bartels was not present in any of the cases.
Symptoms. — Prodromata are not uncommon, but the disease may set
in abruptly with a chill, followed by fever and a severe pain in the side.
It is remarkable, however, with what frequency the disease comes on in-
sidiously. The pain in the side is the most distressing symptom, and is
usually referred to the nipple or axillary regions. It must be remembered,
however, that pleuritic pain may be felt in the abdomen or low down in
the back, particularly when the diaphragmatic surface of the pleura is
involved. It is lancinating, sharp, and severe, and is aggravated by cough.
At this early stage, on auscultation, sometimes indeed on palpation, a dry
friction rub can be detected. The fever rarely rises so rapidly as in pneu-
monia, and does not reach the same grade. A temperature of from 102°
to 103° is an average pyrexia. It may drop to normal at the end of a
week or ten days without the appearance of any definite change in the
physical signs, or it may persist for several weeks. The temperature of
the affected is higher than that of the sound side. Cough is an early
symptom in acute pleurisy, but is rarely so distressing or so frequent as in
pneumonia. There are instances in which it is absent. The expectora-
tion is usually slight in amount, mucoid in character, and occasionally
streaked with blood.
At the outset there may be dyspnoea, due partly to the fever and partly
to the pain in the side. Later it results from the compression of the lung,
particularly if the exudation has taken place rapidly. When, however,
the fluid is effused slowly, one lung may be entirely compressed without
inducing shortness of breath, except on exertion, and the patient will lie
quietly in bed without evincing the slightest respiratory distress. When the
effusion is large the patient usually prefers to lie upon the affected side.
Physical Signs. — Inspection shows some degree of immobility on the
affected side, depending upon the amount of exudation, and in large effu-
ACUTE PLEURISY. 561
sions an increase in volume, which may appear to be much more than it
really is as determined by mensuration. The intercostal spaces are oblit-
erated. In right-sided effusions the apex beat may be lifted to the fourth
interspace or be pushed beyond the left nipple, or may even be seen in the
axilla. When the exudation is on the left side the heart's impulse may
not be visible; but if the effusion is large it is seen in the third and
fourth spaces on the right side, and sometimes as far out as the nipple,
or even beyond it.
Palpation enables us more successfully to determine the deficient
movements on the affected side, and the obliteration of the intercostal
spaces, and more accurately to define the position of the heart's impulse.
In simple sero-fibrinous effusion there is rarely any oedema of the chest
walls. It is scarcely ever possible to obtain fluctuation. Tactile fremitus
is greatly diminished or abolished. If the effusion is slight there may be
only enfeeblement. The absence of the voice vibrations in effusions of
any size constitutes one of the most valuable of physical signs. In children
there may be much effusion with retention of fremitus. In rare cases the
vibrations may be communicated to the chest walls through localized
pleural adhesions.
Mensuration. — With the cyrtometer, if the effusion is excessive, a
difference of from half an inch to an inch, or even, in large effusions, an
inch and a half, may be found between the two sides. Allowance must
be made for the fact that the right side is naturally larger than the left.
With the saddle- tape the difference in expansion between the two sides
can be conveniently measured.
Percussion. — Early in the disease, when the pain in the side is severe
and the friction murmur evident, there may be no alteration, but with
the gradual accumulation of the fluid the resonance becomes defective,
and finally gives place to absolute dulness. From day to day the gradual
increase in height of the fluid may be studied. In a pleuritic effusion
rising to the fourth rib in front, the percussion signs are usually very
suggestive. In the subclavicular region the attention is often aroused at
once by a tympanitic note, the so-called Skoda's resonance, which is
heard perhaps more commonly in this situation with pleural effusion
than in any other condition. It shades insensibly into a flat note in the
lower mammary and axillary regions. Skoda's resonance may be obtained
also behind, just above the limit of effusion. The dulness has a peculiarly
resistant, wooden quality, differing from that of pneumonia and readily
recognized by skilled fingers. It has long been known that when the
patient is in the erect posture the upper line of dulness is not horizontjil,
but is higher behind than it is in front, forming a parabola. Ellis and
Garland, of Ikjston, who have made a careful study of this question, state
that the line of dulness from behind forward may sometimes be repre-
sented by a curved line resembling the letter S. The condition is fully
considered in Garland's exhaustive work on Pneumo-dynamics.
562 DISEASES OF THE RESPIRATORY SYSTEM.
On the right side the dulness passes without change into that of the
liver. On the left side in the nipple line it extends to and may obliterate
Traube's semilunar space. If the effusion is moderate, the phenomenon
of movable dulness may be obtained by marking carefully, in the sitting
posture, the upper limit in the mammary region, and then in the recum-
bent posture, noting the change in the height of dulness. This infallible
sign, of fluid cannot always be obtained. In very copious exudation the
dulness may reach the clavicle and even extend beyond the sternal mar-
gin of the opposite side.
AusniUation. — Early in the disease a friction rub can usually be heard,
which disappears as the fluid accumulates. It is a to-and-fro dry rub,
close to the ear, and has a leathery, creaking character. There is another
pleural friction sound which closely resembles, and is scarcely to be dis-
tinguished from, the fine crackling crepitus of 2:)neumonia. This may be
heard at the commencement of the disease, and also, as pointed out in
1844 by MacDonnell, Sr., of Montreal, Avhen the effusion has receded and
the pleural layers come together again.
"With even a slight exudation there is weakened or distant breathing.
Often inspiration and expiration are distinctly audible, though distant,
and have a tubular quality. Sometimes only a puffing tubular expiration
is heard, which may have a metallic or amphoric quality. Loud resonant
rales accompanying this may forcibly suggest a cavity. These pseudo-
cavernous signs are met with more frequently in children, and often lead
to error in diagnosis. Above the line of dulness the breath-sounds are
usually harsh and exaggerated, and may have a tubular quality.
The vocal resonance is usually diminished or absent. The whispered
voice is said to be transmitted through a serous and not through a puru-
lent exudate (Bacelli's sign). There may, however, be intensification —
bronchophony. The voice sometimes has a curious nasal, squeaking char-
acter, which was termed by Laennec mgopliony^ from its supposed resem-
blance to the bleating of a goat. In typical form this is not common, but
it is by no means rare to hear a curious twang-like quality in the voice,
particularly at the outer angle of the scapula.
In the examination of the heart in cases of pleuritic effusion it is well
to bear in mind that when the apex of the heart lies beneath the sternum
there may be no impulse. The determination of the situation of the organ
may rest with the position of maximum loudness of the sounds. In the
displaced organ a systolic murmur may be heard. When the lappet of lung
over the pericardium is involved on either side there may be a pleuro-peri-
cardial friction.
The course of acute sero-fibrinous pleurisy is very variable. After i)er-
sisting for a week or ten days the fever subsides, the cough and pain dis-
appear, and a slight effusion may be quickly absorbed. In cases in which
the effusion reaches as high as the fourth rib recovery is usually slower.
Manv instances come under observation for the first time, after two or
ACUTE PLEURISY. 5G3
three weeks' indisposition, with the fluid at a level with the clavicle. I'he
fever may last from ten to twenty days without exciting anxiety, though,
as a rule, in ord.inary pleurisy from cold, as we say, the temperature in
cases of moderate severity is normal within eight or ten days. Left to
itself the natural tendency is to resorption ; but this may take place very
slowly. Even after it has persisted for months a sero-fibrinous exudate
may completely disappear. With the absorption of the fluid there is a
redux-friction crepitus, either leathery and creaking or crackling and rale-
like, and for months, or even longer, the defective resonance and feeble
breathing are heard at the base.
A sero-fibrinous exudate may persist for months without change, par-
ticularly in tuberculous cases, and will sometimes reaccumulate after aspi-
ration and resist all treatment. The change of the exudate into pus will
be spoken of in connection with empyema. Death is a rare termination
of sero-fibrinous effusion. When one pleura is full and the heart is greatly
dislocated the condition, although in a majority of cases producing re-
markably little disturbance, is not without risk. Sudden death may occur,
and its possibility under these circumstances should always be considered.
I have seen two instances — one in right and the other in left sided effu-
sion— both due, apparently, to syncope following slight exertion, such as
getting out of bed. In neither case, however, was the amount of fluid
excessive. Weil, who has studied carefully this accident, concludes as
follows: (1) That it may be due to thrombosis or embolism of the heart
or pulmonary artery, cedema of the opposite lung, or degeneration of the
heart muscle ; (2) such alleged causes as mechanical impediment to the
circulation, owing to dislocation of the heart or twisting of the great ves-
sels, require further investigation. It occurs more frequently in right than
in left pleurisies, and the effusion is usually serous. Death may occur
without any premonitory symptoms, usually during some m.ovement or
effort.
III. Purulent Pleurisy {Empyema).
Etiology. — Pus in the pleura is met with under the following con-
ditions: {a) As a sequence of acute sero-fibrinous pleurisy. It is not
always easy to say why, in certain cases, the exudate becomes purulent.
It rarely does so in the acute pleurisies of healthy individuals. In chil-
dren many cases are probably purulent from the outset. Aspiration,
which is said to favor the occurrence of empyema, in my experience does
so very rarely, {h) Purulent pleurisy is common as a secondary inflam-
mation in various infectious diseases, among which scarlet fever takes
the first place. It has long been known that the pleurisy superven-
ing in the convalescence of tliis disease is almost always purulent. It
should be remembered that it is latent in its onset, and tliat there may be
no pulmonary symptoms. The pleurisy following typlioid fever is also
usually purulent. Other infectious diseases — measles and whooping-cough
564: DISEASES OF THE RESPIRATORY SYSTEM.
— are more rarely followed by this complication. Of late years especial
attention has been paid to the connection of pneumonia with empyema,
and it has been shown that very many cases come on insidiously either in
the course of or during convalescence from this disease ; and, lastly, a lim-
ited number of tuberculous pleurisies early become purulent, (c) Em-
pyema results from local causes — fracture of the rib, penetrating wounds,
malignant disease of the lung or oesophagus, and, perhaps most frequently
of all, the perforation of the pleura by tuberculous cavities.
The bacteriology of empyema is of some importance. A sterile exu-
date suggests tuberculosis. In many cases the pneumococci are present,
and these, as a rule, run a very favorable course. The streptococci are
found most commonly in the secondary cases in connection with septic
processes. In a few instances psorosperms have been found in the exu-
date.
Morbid Anatomy. — On opening an empyema post mortem, we
usually find that the effusion has separated into a clear, greenish-yellow
serum above and the thick, cream-like pus below. The fluid may be
scarcely more than turbid, with flocculi of fibrin through it. In other in-
stances it is uniformly thick and creamy, without any fibrin. It usually
has a heavy, sweetish odor, but in some instances — particularly those fol-
lowing wounds — it is fetid. In cases of gangrene of the lung or pleura
the pus has a horribly stinking odor. Microscopically it has the charac-
ters of ordinary pus. The pleural membranes are greatly thickened, and
present a grayish-white layer from 1 to 2 mm. in thickness. On the
costal pleura there may be erosions, and in old cases fistulous communica-
tions are common. The lung may be compressed to a very small limit,
and the visceral pleura also may show perforations.
Symptoms. — Purulent pleurisy may begin abruptly, with the symp-
toms already described. More frequently it comes on insidiously in the
course of other diseases or follows an ordinary sero-fibrinous pleurisy.
There may be no pain in the chest, very little cough, and no dyspncea,
unless the side is very full. Symptoms of septic infection are rarely
wanting. If in a child, there is a gradually developing pallor and weak-
ness ; sweats occur, and there is irregular fever. A cough is by no means
constant.
Physical Signs. — Practically they are those already considered in pleu-
risy with effusion. There are, however, one or two additional points to
be mentioned. In empyema, particularly in children, the disproportion
between the sides may be extreme. The intercostal spaces may not only
be obliterated, but may bulge. Much more frequently there is oedema of
the chest walls. The network of subcutaneous veins may be very distinct.
It must not be forgotten that in children the breath-sounds may be loud
and tubular over a purulent effusion of considerable size. Whispered
pectoriloquy is usually not heard in empyema (Bacelli's sign). The dis-
location of the heart and the displacement of the liver are more marked
ACUTE PLEURISY. 565
in empyema than in sero-fibrinous effusion — probably, as Senator suggests,
owing to the greater weight of the fluid.
A curious phenomenon associated generally with empyema, but which
may occur in the sero-fibrinous exudate, is pulsati7ig pleurisy^ first de-
scribed by MacDonnell, Sr., of Montreal. Of 42 cases 39 occurred on
the left side. In all but one case the fluid was purulent. Pneumothorax
may be present. There are two groups of cases, the intrapleural pulsat-
ing pleurisy and the pulsating empyema 7iecessitatis, in which there is an
external pulsating tumor. No satisfactory explanation has been offered
how the heart impulse is thus forcibly communicated through the effusion.
Empyema is a chronic affection, which in a few instances terminates
naturally in recovery, but a majority of cases, if left alone, end in death.
The following are some modes of natural cure : (a) By absorption of
the fluid. In small effusions this may take place gradually. The chest
wall sinks. The pleural layers become greatly thickened and enclose be-
tween them the inspissated pus, in which lime salts are gradually deposited.
Such a condition may be seen once or twice a year in the post-mortem
room of any large hospital, (b) By perforation of the lung. Although
in this event death may take place rapidly, by inundation of the bronchial
tubes, yet in many cases it occ^^rs gradually and recovery follows. Since
1873, when I saw a case of this kind in Traube's clinic, and heard his
remarks on the subject, I have seen a number of instances of the kind
and can corroborate his statement as to the favorable termination of many
of them. Empyema may discharge either by opening into the bronchus
and forming a fistula or, as Traube pointed out, by producing necrosis of
the pulmonary pleura, sufficient to allow the soakage of the pus through
the spongy lung tissue into the bronchi. In the first way pneumothorax
usually, though not always, develops. In the second way the pus is dis-
charged without formation of pneumothorax. Even with a bronchial
fistula recovery is possible. (6*) By perforation of the chest wall — empyema
necessitatis. This is by no means an unfavorable method, as many cases
recover. The perforation may occur anywhere in tlie chest wall, but is,
as Cruveilhier remarked, more common in front. It may be anywhere
from the third to the sixth interspace, usually, according to Marshall, in
the fifth. It may perforate in more than one place, and there may be a
fistulous communication which opens into the pleura at some distance
from the external orifice. The tumor, when near the heart, may pulsate.
The discharge may persist for years. In Copeland's Dictionary is men-
tioned an instance of a Bavarian physician who had a pleural fistula for
thirteen years and enjoyed fairly good health.
An empyema may perforate the neighboring organs, the (Esophagus,
peritonaeum, pericardium, or the stomach. Very remarkable cases are
those which pass down the spine and along the psoas into the iliac fossa.,
and simulate a psoas or lumbar abscess.
566 DISEASES OF THE RESPIRATORY SYSTEM.
IV. Tuberculous Pleurisy.
This lias already been considered. Here it is sufficient to say that it
occurs as : (a) An acute affection, accompanied by abundant sero-fibrinous
fluid. In this category come certainly a proportion of the cases regarded
as acute pleurisy from cold. (^) As a subacute affection, latent in its
origin and insidious in its course, frequently preceding the development
of or coming on concurrently with pulmonary tuberculosis, (c) As an
acute pleurisy, the result of direct extension from the lung in cases of
well-marked phthisis, and in which the fluid may be either sero-fibrinous
or purulent, (d) Chronic adhesive tuberculous pleurisy, which may be
unilateral or bilateral, unaccompanied by exudation and characterized by
great thickening of the pleural membranes, in which are tubercles and
caseous masses of varying sizes.
The symptoms and physical signs of tuberculous pleurisy with exuda-
tion do not require any description other than that already given in con-
nection with the sero-fibrinous and purulent forms.
V. Other Varieties of Pleurisy.
Hsemorrliagic Pleurisy. — A bloody effusion is met with under the fol-
lowing conditions : (a) In the pleurisy of asthenic states, such as cancer,
Bright's disease, and occasionally in the malignant fevers. It is inter-
esting to note the frequency with which haemorrhagic pleurisy is found
in cirrhosis of the liver. It occurred in the very patient in whom Laennec
first accurately described this disease. AVhile this may be a simple
haemorrhagic pleurisy, in a majority of the cases which I have seen it
has been tuberculous, (b) Tuberculous pleurisy, in which the bloody
effusion may result from the rupture of newly formed vessels in the soft
exudate accompanying the eruption of miliary tubercles, or it may come
from more slowly formed tubercles in a pleurisy secondary to extensive
pulmonary disease, (c) Cancerous pleurisy, whether primary or second-
ary, is frequently haemorrhagic. (cl) Occasionally haemorrhagic exudation
is met with in perfectly healthy individuals, in whom there is not the
slightest suspicion of tuberculosis or cancer. In one such case, a large,
able-bodied man, the patient was to my knowledge healthy and strong
eight years afterward. And, lastly, it must be remembered that during
aspiration the lung may be wounded and blood in this way get mixed
with the sero-fibrinous exudate. The condition of hasmorrhagic pleurisy
is to be distinguished from hcemothorax, due to the rupture of aneurism
or the pressure of a tumor on tlie thoracic veins.
Diaphragmatic Pleurisy. — The inflammation may be limited partly or
chiefly to tlie diaj)liragmatic surface. This is often a dry pleurisy, but
there may be effusion, either sero-fibrinous or purulent, which is circum-
scribed on the diaphragmatic surface. In these cases the pain is low in
ACUTE PLEUmSY. 567
the zone of the diaphragm and, as Gueneau de Mussy pointed out, may
be intensified by pressure at the point of insertion of the diaphragm at
the tenth rib. The diaphragm is fixed and the respiration is thoracic
and short. Andral noted in certain cases severe dyspnoea and attacks
simulating angina. As mentioned, the effusion is usually plastic, not
serous. Serous or purulent effusions of any size limited to the diaphrag-
matic surface are extremely rare.
Encysted Pleurisy. — The effusion may be circumscribed by adhesions
or separated into two or more pockets or loculi, which communicate with
each other. This is most com.mon in empyema. In these cases there
have usually been, at different parts of the pleura, multijDie adhesions by
which the fluid is limited. In other instances the recent false membranes
may encapsulate the exudation on the diaphragmatic surface, for example,
or the part of the pleura posterior to the mid-axillary line. The con-
dition may be very puzzling during life, and present special difficulties in
diagnosis. In some cases the tactile fremitus is retained along certain
lines of adhesion. The exploratory needle should be freely used when
there is any doubt.
Interlobar Pleurisy forms an interesting and not uncommon variety.
In nearly every instance of acute pleurisy the interlobular serous surfaces
are also involved and closely agglutinated together, and sometimes the
fluid is encysted between them. In a recent case of this kind following
pneumonia, there was between the lower and upper and middle lobes of
the right side an enormous purulent collection, which looked at first like
a large abscess of the lung. These collections may perforate the bronchi,
and the cases present special difficulties in diagnosis.
Diagnosis of Pleurisy. — Acute plastic pleurisy is readily recog-
nized. In the diagnosis of pleuritic effusion the first question is. Does a
fluid exudate exist ? the second, What is its nature ? In large effusions
the increase in the size of the affected side, the immobility, the absence of
tactile fremitus, together with the displacement of organs, give infallible
indications of the presence of fluid. The chief difficulty arises in effusions
of moderate extent, when the dulness, the presence of bronchophony,
and, perhaps, tubular breathing may simulate pneiwioma. The chief
points to be borne in mind are : (a) Differences in the onset and in the
general characters of the two affections, more particularly the initial chill,
the higher fever, more urgent dyspnoea, and the rusty expectoration, which
characterize pneumonia, (h) Certain physical signs — the more wooden
character of the dulness, the greater resistance, and the marked diminu-
tion or the absence of tactile fremitus in pleurisy. The auscultatory signs
may be deceptive. It is usually, indeed, the persistence of tubular breath-
ing, particularly the high-pitched, even amphoric expiration, heard in
some cases of pleurisy, which has raised the doubt. The intercostal spaces
arc more commonly obliterated in pleuritic effusion than in pneumonia.
As already mentioned, the displacement of organs is a very valuable sign.
568 DISEASES OF THE RESPIRATORY SYSTEM.
Nowadays with the hypodermic needle the question is easily settled. A
separate small syringe with a capacity of two drachms should be reserved
for exploratory purposes, and the needle should be longer and firmer
than in the ordinary hypodermic instrument. AVith careful preliminary
disinfection the instrument can be used with impunity, and in cases of
doubt the exploratory puncture should be made without hesitation.
I have never seen the slightest ill effects follow its use. Cases are
reported of pneumothorax resulting from it, but they are extremely
rare. The hypodermic needle is especially useful in those cases in which
there are pseudo-cavernous signs at the base. In cases, too, of massive
pneumonia, in which the bronchi are plugged with fibrin, if the patient
has not been seen from the outset, the diagnosis may be impossible with-
out it.
On the left side it may be difficult to differentiate a very large peri-
cardial from a pleural effusion. The retention of resonance at the base,
the presence of Skoda's resonance toward the axilla, the absence of dis-
location of the heart-beat to the right of the sternum, the feebleness of
the pulse and of the heart-sounds, and the urgency of the dyspnoea, out
of all proportion to the extent of the effusion, are the chief points to be
considered. Unilateral hydrothorax, which is not at all uncommon in
heart-disease, presents signs identical with those of sero-fibrinous effusion.
Certain tumors within the chest may simulate pleural effusion. It should
be remembered that many intrathoracic growths are accompanied by exu-
dation. Malignant disease of the lung and of the pleura and hydatids of
the pleura produce extensive dulness, with suppression of the breath-
sounds, simulating closely effusion.
On the right side abscess of the liver and hydatid cysts may rise
high into the pleura and produce dulness and enfeebled breathing. Often
in these cases there is a friction sound, which should excite suspicion,
and the upper outline of the dulness is sometimes plainly convex. In all
these instances the exploratory puncture should be made.
The second question, as to the nature of the fluid, is quickly decided
by the use of the needle. The persistent fever, the occurrence of sweats,
and the increase in the pallor suggest the presence of pus. In children
the complexion is often sallow and earthy. The unexpected, however,
often happens, and repeatedly, in protracted cases, even in children, when
the general symptoms and the appearance of the patient has been most
strongly suggestive of pus, the syringe has withdrawn clear fluid. On
the other hand, effusions of short duration may be purulent, even when
the general symptoms do not suggest it. The following statement may
be made with reference to the prognostic import of the bacteriological
examination of the aspirated fluid : The presence of the pneumococcus is
of favorable significance, as such cases usually get well rapidly, even with
a single aspiration. The pus organisms — staphylococci and streptococci —
are more common in empyema of septic origin, and such cases are notori-
ACUTE PLEURISY. 569
ously less hopeful than others. A sterile fluid indicates in a majority o2
instances a tuberculous origin.
Treatment. — At the onset the severe pain may demand leeches,
which usually give relief, but a hypodermic of morphia is more effective.
The Paquelin cautery may be lightly but freely applied. It is well to
administer a mercurial or saline purge. Fixing the side by careful strap-
ping with long strips of adhesive plaster, which should pass well over the
middle line, drawn tightly and evenly, gives great relief, and I can cor-
roborate the statement of F T. Roberts as to its efficacy. Cupping, wefc
or dry, is now seldom employed. Blisters are of no special service in the
acute stages, although they relieve the pain. The ice-bag may be used as
in pneumonia. The general treatment of the early stage should be rest
in bed and a liquid diet. Medicines are rarely required. A Dover's
powder may be given at night. Mercurials are not indicated.
When the effusion has taken place, mustard plasters or iodine, pro-
ducing slight counter-irritation, appear useful, particularly in the later
stages. The following rational plan is successful in some cases. It is
based upon the idea that if the blood serum is depleted or if it is kept
concentrated, the liquid will be absorbed from the lymph spaces, of which
the pleura is one, to equalize the loss. To do this the patient should
have the daily amount of liquid food greatly restricted. If there is no
fever, a meat diet, with an egg and dry bread and eight to ten ounces
of liquid in the form of milk or water, should be given. Salt articles of
food may be used, but I do not think it necessary to give, as some do,
doses of salt. The second element in the treatment is the active depletion
of blood serum, which is effected in the way introduced by Mat-thew Hay.
Every morning, if the patient is robust, otherwise every second morning,
from half an ounce to an ounce and a half of Epsom salts is given an hour
before breakfast, in as concentrated a form as is possible. This produces
copious liquid discharges. I have seen large exudations disappear rapidly
when this plan was followed. By acting upon the skin and kidneys, the
same end may be obtained, but with much less certainty. The vapor or
hot bath may be used and an occasional dose of pilocarpin. Diuretics,
such as digitalis, squills, and acetate of lead, may sometimes be required.
I rarely resort, however, to diuretics or diaphoretics in the treatment of
pleurisy with effusion. Iodide of potassium is of doubtful benefit.
Aspiration of the fluid is the most thorough and satisfactory method
and should be resorted to whenever the effusion becomes large or if it re-
sists the ordinary methods of treatment. The credit of introducing aspi-
ration in pleuritic effusions is due to Morrill Wyman, of Cambridge, Mass.,
and Henry I. Bowditch, of Boston. Years prior to Dieulafoy's work, as-
piration was in constant use at the Massachusetts General Hospital and
was advocated repeatedly by Bowditch. As the question is one of some
historical interest, I give the author's conclusions concerning aspiration,
expresHcd more than forty years ago, and which practically represent
570 DISEASES OF THE RESPIRATORY SYSTEM.
the opinion of clinical physicians to-day : " (1) The operation is perfectly
simple, but slightly painful, and can be done with ease upon any patient
in however advanced a stage of the disease. (2) It should be performed
forthwith in all cases in which there is complete filling up of one side of
the chest. (3) lie had determined to use it in any case of even moderate
effusion lasting more than a few weeks and in which there should seem
to be an indisposition to resist ordinary modes of treatment. (4) lie
urged this practice upon the profession as a very im23ortant measure in
practical medicine ; believing that by this method death may frequently
be prevented from ensuing either by sudden attack of dyspnoea or subse-
quent phthisis, and, finally, from the gradual wearing out of the powers
of life or inability to absorb the fluid. (5) He believed that this operation
would sometimes prevent the occurrence of those tedious cases of spon-
taneous evacuation of purulent fluid and those great contractions of the
chest which occur after long-continued effusion and the subsequent dis-
charge or absorption of a fluid."
There is scarcely anything to be added to-day to these observations.
When the fluid reaches to the clavicle the indication for aspiration is im-
perative, even though the patient be comfortable and present no signs of
pulmonary distress. The presence of fever is not a contra-indication ;
indeed, sometimes with serous exudates the temperature falls after aspi-
ration.
The operation is extremely simple and is practically without risk.
The spot selected for puncture should be either in the seventh interspace
m the mid-axilla or at the outer angle of the scapula in the eighth inter-
space. The arm of the patient*"should be brought forward with the hand
on the opposite shoulder, so as to Aviden the interspaces. The needle
should be tlirust in close to the upper margin of the rib, so as to avoid the
intercostal artery, the wounding of Avhich, however, is an excessively rare
accident. The fluid should be withdrawn slowly. The amount will de-
pend on the size of the exudate. If the fluid reaches to the clavicle a
litre or more may be withdrawn with safety.
During aspiration if the patient feels faint it is best to interrupt the
operation, for sudden death has occasionally happened during the with-
drawal. It is, however, a much less common accident than sudden death
in cases of full pleura without operation. Cough is a symptom whicli
frequently develops toward the close of aspiration. Though very painful
it need not excite alarm. French writers have described cases of albumi-
nous expectoration, associated with dyspnoea, which may come on after
the tapping and prove rapidly fatal. It must be an excessively rare com-
plication. The conversion of a sero-fibrinous into a purulent fluid is a
danger wliich need not be considered. I have never met with an instance
of the kind.
Empyema is really a surgical affection, and I shall make only a few
general remarks upon its treatment. When it has been determined by
CHRONIC PLEURtSY. 571
exploratory puncture that tlie fluid is purulent, aspiration should not he
performed, except as preliminary to operation or as a temporary measure.
Perhaps it is better not to have an exception to this rule, although the
empyemas of children and the pneumonic empyema occasionally get well
rapidly after a single tapping. It is sad to think of the number of lives
which are sacrificed annually by the failure to recognize tliat empyema
should be treated as an ordinary abscess, by free incision. The operation
dates from the time of Hippocrates and is by no means serious. A ma-
jority of the cases get well, providing that free drainage is obtained, and
it makes no difference practically what measures are followed so long as
this indication is met. The good results in any method depend upon
the thoroughness with which the cavity is drained. Irrigation of the
cavity is rarely necessary unless the contents are fetid. Sudden collapse
has happened during irrigation and a remarkable accident is the occur-
rence of convulsions. In the subsequent treatment a point of great im-
portance in facilitating the closure of the cavity is the distention of the
lung on the affected side. This may be accomplished by the method
advised by Walter James, which has been practised w4th great success in
the surgical wards of the Johns Hopkins Hospital. The patient daily,
for a certain length of time, increasing gradually with the increase of his
strength, transfers by air-pressure water from one bottle to another. The
bottles should be large, holding at least a gallon each, and by the arrange-
ment of tubes, as in the Wolff's bottle, an expiratory effort of the patient
forces the water from one bottle into the other. In this way expansion
of the compressed lung is systematically practised. The abscess cavity is
gradually closed, partly by the falling in of the chest wall and partly by
the expansion of the lung. In some instances it is necessary to resect
portions of one or more ribs.
The physician is often asked, in cases of empyema with emaciation,
hectic and feeble rapid pulse, whether the patient could stand the opera-
tion. Even in the most desperate cases the surgeon should never hesitate
to make a free incision.
II. CHRONIC PLEURISY.
This affection occurs in two forms : (1 ) Chronic pleurisy ivith effusion^
in which the disease may set in insidiously or may follow an acute sero-
fibrinous pleurisy. There are cases in which the liquid persists for months
without undergoing any special alteration and without becoming purulent.
Such cases have the characters which we have described under pleurisy
with effusion. (2) Chronic dry pleurisy. The cases are met with (a) as
a sequence of ordinary j)leural eff'usion. When tlie exudate is absorbed
and the layers of the pleura come together there is left between them a
variable amount of fibrinous material which gradually undergoes organi-
37
572 DISEASES OF THE RESPIRATORY SYSTEM.
zation, and is converted into a layer of firm connective tissue. This pro-
cess goes on at the base, and is represented clinically by a slight grade of
flattening, deficient expansion, defective resonance on percussion, and en-
feebled breathing. After recovery from empyema the flattening and re-
traction may be still more marked. In both cases it is a condition which
can be greatly benefited by pulmonary gymnastics. In these firm, fibrous
membranes calcification may occur, particularly after empyema. It is
not very uncommon to find between the false membranes a small pocket
of fluid forming a sort of pleural cyst. In the great majority of these
cases the condition is one which need nQ]t cause anxiety. There may be
an occasional dragging pain at the base of the lung or a stitch in the side,
but patients may remain in perfectly good health for years. The most
advanced grade of this secondary dry pleurisy is seen in those cases of em-
pyema w^hich have been left to themselves and have perforated and ulti-
mately healed by a gradual absorption or discharge of the pus, with retrac-
tion of the side of the chest and permanent carnification of the lung.
Traumatic lesions, such as gunshot wounds, may be followed by an identi-
cal condition. Post mortem, it is quite impossible to separate the layers
of the pleura, which are greatly thickened, particularly at the base, and
surround a compressed, airless, fibroid lung.
(b) Primitive dry pleurisy. This condition may directly follow the
acute plastic pleurisy already described ; but it may set in without any
acute symptoms whatever, and the patient's attention may be called to it
by feeling the pleural friction. A constant effect of this primitive dry
pleurisy is the adhesion of the layers. This is probably an invariable result,
whether the pleurisy is primary or secondary. The organization of the thin
layer of exudation in a pneumonia will unite the two surfaces by delicate
bands. Pleural adhesions are extremely common, and it is rare to examine
a body entirely free from them. They may be limited in extent or univer-
sal. Thin fibrous adhesions do not produce any alteration in the percussion
characters, and, if limited, there is no special change heard on ausculta-
tion. When, however, there is general synechia on both sides the expan-
sile movement of the lung is considerably impaired. We should naturally
think that universal adhesions would interfere materially with the func-
tion of the lungs, but practically we see many instances in which there
has not been the slightest disturbance. The physical signs of total adhe-
sion are by no means constant. It has been stated that there is a marked
disproportion between the degree of expansion of the chest walls and the
intensity of the vesicular murmur, but the latter is a very variable factor,
and under perfectly normal conditions the breath-sounds, with very full
chest expansion, may be extremely feeble.
Is there a primitive dry pleurisy which gradually leads to great thick-
ening of the membranes, and which ultimately may invade the lung and
induce cirrhotic change? Upon this question neithei pathologists nor
clinicians agree. I think that Sir Andrew Clark, in his Lumleian lectures
CHRONIC PLEURISY. 573
at the Royal College of Physicians (1885), luis made good his claim that
such a disease does exist. At the outset in these cases tliere is a dry
pleurisy, usually at one base, indicated by the usual signs ; and this per-
sists in spite of all treatment. There- is no evidence of fluid ; the general
health may not be much impaired, or there may be slight fever and dis-
turbed digestion. The cases give great anxiety, owing to the natural
suspicion that tuberculosis exists. In time the evidence of dulness is
found at the base. There are feeble breathing and creaking, leathery
friction sounds. There may be commencing retraction of the side. Clini-
cally these cases are of great interest, and should, I think, be separated,
on the one hand, from the condition which follows a healed empyema or
old pleurisy with effusion, and, on the other, from the rare instances of
primitive cirrhosis of the lung. However, in all three states there may
ultimately be an almost identical clinical picture. Anatomically in these
pleuritic cases the pleura, particularly that surrounding the lower lobe,
sometimes the entire membrane, is thickened, the two layers are inti-
mately united, and fibrinous bands passing from the pleura traverse the
lung tissue, sometimes dividing it in a remarkable way into sections. The
bronchi may present marked dilatations, though this is not always the
case, and the lung tissue is more or less sclerosed. The cases belong to
the group of chronic pneumonias called by Charcot pleurogenous. In
many instances there can be no question as to their non-tuberculous
nature. There are cases, however, in which, with chronic pleurogenous
pneumonia in the lower lobe, there are cavity formations at the apex and
tuberculous lesions in other parts. Such may, of course, be tuberculous
from the outset.
Lastly, there is a primitive dry pleurisy of tuberculous origin. In it
both parietal and costal layers are greatly thickened — perhaps from two
to three millimetres each — and present firm fibroid, caseous masses and
small tubercles, while uniting these two greatly thickened layers is a
reddish-gray fibroid tissue, sometimes infiltrated with serum. This may
be a local process confined to one pleura, or it may be in both. I have
seen two typical instances of it — one in a young, well-nourished Irish girl,
who died of malignant scarlet fever, in whom one pleura was in the con-
dition above described, and there were no other tuberculous lesions. The
other was in a young man who died of typhoid fever, in whom both pleurae
were uniformly thickened and tuberculous without any fluid exudate.
Those cases are sometimes associated with a similar condition of the peri-
cardium and peritonaeum.
Occasionally remarkable vaso-motor phenomena occur in chronic pleu-
risy, whether simple or in connection with tuberculosis of an apex. Flush-
ing or sweating of one cheek or dilatation of the pupil are the common
manifestations. They appear to be due to involvement of the first thoracic
ganglion at the top of the pleural cavity.
574 DISEASES OF THE RESPIRATORY SYSTEM.
III. HYDROTHORAX.
Hydrothorax is a transudation of simple non-inflammatory fluid into
the pleural cavities, and occurs as a secondary process in many affections.
The fluid is clear, without any flocculi of fibrin, and the membranes are
smooth. It is met with more particularly in connection with general
dropsy, either renal, cardiac, or haemic. It may, however, occur alone, or
with only slight oedema of the feet. A child was admitted to the Mont-
real General Hospital with urgent dyspnoea and cyanosis, and died the
night after admission. She had extensive bilateral hydrothorax, which
had come on early in the nephritis of scarlet fever. In renal disease
hydrothorax is almost always bilateral, but in heart affections one pleura
is more commonly involved. The physical signs are those of pleural effu-
sion, but the exudation is rarely excessive. In kidney and heart disease,
even when there is no general dropsy, the occurrence of dyspnoea should
at once direct attention to the pleura, since many patients are carried off
by a rapid effusion. Post-mortem records show the frequency with which
this condition is overlooked. The saline purges will in many cases rapid-
ly reduce the effusion, but, if necessary, aspiration should repeatedly be
practised.
IV. PNEUMOTHORAX {Hydro-Piieumothorax and Pyo- Pneumothorax).
Air alone in the pleural cavity, to which the term pneumothorax is
strictly applicable, is an extremely rare condition. It is almost invariably
associated with a serous fluid — hydro-pneumothorax, or with pus — pyo-
pneumothorax.
Etiology. — It has usually been taught that there is an inherent
tendency to pneumothorax, which is induced as soon as the pleura is
opened. The experiments of S. West seem, however, to indicate the
existence of a coherent force between the pleural surfaces much in excess
of the elasticity of the lung, and sufficient in certain instances to main-
tain these organs in contact with the thoracic wall, even when there is
free access to the pleura ; so that in reality force is required to overcome
the normal adhesion between the pleural membranes.
Pneumothorax arises : (1) In perforative wounds of the chest, in which
case it is sometimes associated with extensive cutaneous emphysema. It
has followed exploratory puncture with a hypodermic needle, as in two
cases reported by Herman Biggs. Pneumothorax rarely follows fracture
of the rib, even though the lung may be torn. (2) In perforation of the
pleura through the diaphragm, usually by malignant disease of the
stomach or colon. The pleura may also be perforated in cases of cancer
of the oesophagus. (3) When the lung is perforated. This is by far the
most common cause, and may occur : (a) In a normal lung from rupture
PNEUMOTnORAX. 575
of the air-vesicles during straining. Special attention has lately been
called to this accident by S. West and De H. Hall. The air may be ab-
sorbed and no ill effect follows. It does not necessarily excite pleurisy, as
pointed out many years ago by Gairdner, but inflammation and effusion
are the usual result, (b) From perforation due to local disease of the
lung, either the softening of a caseous focus or the breaking of a tuber-
culous cavity. According to S. West, ninety per cent of all the cases are
due to this cause. Less common are the cases due to septic broncho-
pneumonia and to gangrene. A rare cause is the breaking of a haemor-
rhaofic infarct in chronic heart-disease, of which I met an instance a few
years ago. (c) Perforation of the lung from the pleura, which arises in
certain cases of empyema and produces a pleuro-bronchial fistula.
Pneumothorax occurs chiefly in adults, though cases are met with in
very young children. It is more frequent in males than in females.
Morbid Anatomy. — If a trocar or blow-pipe is inserted between
the ribs, there may be a jet of air of suflftcient strength to blow out a
lighted match. On opening the thorax the mediastinum and pericardium
are seen to be pushed, or rather, as Douglas Powell pointed out, drawn
over to the opposite side ; but, as before mentioned, the heart is not
rotated, and the relation of its parts is maintained much as in the normal
condition. A serous or purulent fluid is usually present, and the mem-
branes are inflamed. The cause of the pneumothorax can usually be
found without difficulty. In the great majority of instances it is the
perforation of a tuberculous cavity or a breaking of a superficial caseous
focus. The orifice of rupture may be extremely small. In chronic cases
there may be a fistula of considerable size communicating with the bron-
chi. The lung is usually compressed and carnified.
Symptoms. — The onset is usually sudden and characterized by
severe pain in the side, urgent dyspnoea, and signs of general distress,
as indicated by slight lividity and a very rapid and feeble pulse. There
may, however, be no urgent symptoms, particularly in cases of long-
standing phthisis. On more than one occasion I have found, post mortem,
a pneumothorax which was unsuspected during life. W^est states that
even in healthy adults this latent pneumothorax may occasionally occur.
The pliyHical signs are very distinctive. Inspection show^s marked
enlargement of the affected side with immobility. The heart impulse is
usually much displaced. On palpation the fremitus is greatly diminished
or more commonly abolished. On percussion the resonance may be tym-
panitic or even have an amphoric quality. This, however, is not always
the case. It may be a flat tympany, resembling Skoda's resonance. In
some instances it may be a full, hyperresonant note, like emphysema;
while in others — and this is very deceptive — there is dulness. These
extreme variations depend doubtless upon the degree of intrapleural ten-
sion. On several occasions I have known an error in diagnosis to result
from ignorance of the fact that, in certain instances, the percussion note
576 DISEASES OF THE RESPIRATORY SYSTEM.
may be " muffled, toneless, almost dull " (Walshe). There is usually
dulness at the base from effused fluid, which can readily be made to
change the level by altering the position of the patient. Movable dulness
can be obtained much more readily in pneumothorax than in a simple
pleurisy. On auscultation the breath-sounds are suppressed. Sometimes
there is only a distant feeble inspiratory murmur of marked amphoric
quality. The contrast between the loud exaggerated breath-sounds on
the normal side and the absence of the breath-sounds on the other is
very suggestive. The rales have a peculiar metallic quality, and on
coughing or deep inspiration there may be what Laennec termed the
metallic tinkling. The voice, too, has a curious metallic echo. What is
sometimes called the coin-sound, termed by Trousseau the hruit cPairairi^
is very characteristic. To obtain it the auscultator should place one ear
on the back of the chest wall while the assistant taps one coin on another
on the front of the chest. The metallic echoing sound which is produced
in this way is one of the most constant and characteristic signs of pneumo-
thorax. And, lastly, the Hippocratic succussion may be obtained when
the auscultator's head is placed upon the patient's chest and his body
shaken. A splashing sound is produced, which may be audible at a dis-
tance. A patient may himself notice it in making abrupt changes in
posture. Of other symptoms displacement of organs is most constant.
As already mentioned, the heart may be drawn over to the opposite side,
and the liver greatly displaced, so that its upper surface is below the level
of the costal margin, a degree of dislocation never seen in simple effusion.
The diagnosis of pneumotlrerax rarely offers any difficulty, as the signs
are very characteristic. In cases in which the percussion note is dull the
condition may be mistaken for effusion. I made this mistake in a case of
pulsating pleurisy, in which the pneumothorax followed heavy lifting, and
it was not until several days later, after some of the fluid had been with-
drawn, that a tympanitic note developed. Diaphragmatic hernia follow-
ing a crush or other accident may closely simulate pneumothorax.
In cases of very large phthisical cavities with tympanitic percussion
resonance and rales of an amphoric, metallic quality the question of
pneumothorax is sometimes raised. In those rare instances of total ex-
cavation of one lung the amphoric and metallic phenomena may be most
intense, but the absence of dislocation of the organs and of the succus-
sion splash and of the coin sound suffice to differentiate this condition.
Why the coin sound is not heard it is difficult to determine, unless its
production is connected in some way with a certain degree of air-tension,
which is not present in a vomica, however large. The condition of pyo-
pneumothorax subphrenicus may simulate closely true pneumothorax.
The prognosis in cases of pneumothorax depends largely upon the
cause. The phthisical cases usually die within a few weeks. Pneumo-
thorax developing in a healthy individual often ends in recovery. There
are cases of phthisis in which the pneumothorax, if occurring early, seems
AFFECTIONS OF THE MEDIASTINUM. 577
to arrest the progress of the tuberculosis. This appeared to be the case in
a man with chronic pneumothorax who was under my care in Philadelphia
for between three and four years. It may be a chronic condition, as in
the case just mentioned, and a fair rneasure of health may be enjoyed.
Treatment. — Practically these cases should be dealt with as ordinary
pleurisy with effusion. Of course, when pneumothorax develops in ad-
vanced phthisis the indication is to relieve the pain and distress either by
morphia or chloroform ; but in cases which develop early the fluid should
be withdrawn by aspiration, or, if purulent, permanent drainage should be
obtained. Even when the condition has seemed to be most desperate I
have known recovery to take place after thorough drainage of the sac.
Portions of ribs may have to be excised, and during convalescence it is
well for the patient to practise expansion of the lung in the manner
already mentioned. There are cases of pneumothorax in phthisis in
which the general condition is so good and the inconvenience so slight
that to let well enough alone seems the best course. In such an occa-
sional aspiration may be performed if the fluid increases. In some of the
instances the mere tapping of the chest with a fine needle, so as to allow
the escape of some of the air, seems to give relief by reducing the intra-
thoracic pressure. Good results are stated to have followed the method
introduced by Potain, of replacing the air and fluid within the thorax by
sterilized air.
AFFECTIONS OF THE MEDIASTINUM.
(1) Simple Lymphadenitis.— In all inflammatory affections of the
bronchi and of the lungs the groups of lymph glands in the mediastinum
become swollen. In the bronchitis of measles, for example, and in simple
broncho-pneumonia the bronchial glands are large and infiltrated, the
tissue is engorged and cedematous, sometimes intensely hyperaemic. Much
stress has been laid by some writers on this enlargement of the glands in
the posterior mediastinum, and De Mussy held that it was an important
factor in inducing paroxysms of whooping-cough. They may attain a
size sufficient to induce dulness beneath the manubrium and in the upper
part of the interscapular regions behind, though this is often difficult to
determine. In reality the glands lie chiefly upon the spine, and unless
those which are deep in the root of the lung are large enough to induce
compression of the adjacent lung tissue, I doubt if the ordinary bronchial
adenopathy ever can be determined by percussion in the upper interscapu-
lar region. I have never met with an instance in which the compression
of either bronchus seemed to have resulted from the glands, however large.
Tuberculous affection of these glands has already been considered.
(2) Suppurative Lymphadenitis. — Occasionally abscess in the bronchial
or tracheal lymph glands is found. It may follow the simple adenitis, but
578 DISEASES OP THE RESPIRATORY SYSTEM.
is most frequently associated with the presence of tubercle. The liquid
portion may gradually become absorbed and the inspissated contents un-
dergo calcification. Serious accident occasionally occurs, as perforation
into the oesophagus or into a bronchus,
(3) Tumors; Cancer and Sarcoma. — In Hare's elaborate study of 520
cases of disease of the mediastinum* there were 134 cases of cancer, 98
cases of sarcoma, 21 cases of lymphoma, 7 cases of fibroma, 11 cases of
dermoid cysts, 8 cases of hydatid cysts, and instances of lipoma, gumma,
and enchondroma. From this we see that cancer is the most common
form of growth. The tumor occurred in the anterior mxcdiastinum alone
in 48 of the cases of cancer and 33 of the cases of sarcoma. The disease
may be either primary in the mediastinal tissues and lymph structures or
secondary. Sarcoma is more frequently primary than cancer. Males are
more frequently affected than females. The age of onset is most com-
monly between thirty and forty.
Symptoms. — The signs of mediastinal tumor are those of intra-
thoracic pressure. Dyspnoea is one of the earliest and most constant
symptoms, and may be due either to pressure on the trachea or on the
recurrent laryngeal nerves. It may indeed be cardiac, due to pressure
upon the heart or its vessels. In a few cases it results from the pleural
effusion which so frequently accompanies intrathoracic growths. Asso-
ciated with the dyspnoea is a cough, often severe and paroxysmal in char-
acter, with the brazen quality of the so-called aneurismal cough when a
recurrent nerve is involved. The voice may also be affected from a simi-
lar cause. Pressure on the vessels is common. The superior vena cava
may be compressed and obliterated, and when the process goes on slowly
the collateral circulation may be completely effected. Less commonly
the inferior vena cava or one or other of the subclavian veins is com-
pressed.' The arteries are much less rarely obstructed. It is remarkable
how little the aorta may be involved, though entirely surrounded by a sar-
comatous or cancerous mass. There may be dysphagia, due to compres-
sion of the oesophagus. In rare instances there are pupillary changes,
either dilatation or contraction, due to involvement of the sympathetic.
Physical Signs. — On inspection there may be orthopnoea and marked
cyanosis of the upper part of the body. In such instances, if of long
duration, there are signs of collateral circulation and the superficial mam-
mary and epigastric veins are enlarged. In a patient with Hodgkin's dis-
ease, at present under observation and in whom during the past sixteen
months there has been progressive compression and now obliteration of
the superior vena cava, the entire subcutaneous tissue of the front of tl>e
thorax seems a plexus of veins and the epigastric vessels are as large as
the index-finger. Such instances are, I think, more common in lymphade-
noma than in sarcoma or cancer. In these cases of chronic obstruction
* Fothergillian Prize Essay of the Medical Society of London, Philadelphia, 1889.
AFFECTIONS OF THE MEDIASTINUM. 579
tlie finger-tips may be clubbed. There may be bulging of the sternum or
the tumor may erode the boue and form a prominent subcutaneous growth.
The rapidly growing lymphoid tumors more commonly than others per-
forate the chest wall. In four of thirteen cases of Ilodgkin's disease, of
which I have notes, there was mediastinal growth, and in three instances
the sternum was eroded and perforated. The perforation may be on one
side of the breast-bone. The projecting tumor may pulsate like an aneu-
rism ; the heart may be dislocated and its impulse much out of place. Con-
traction of one side of the thorax has been noted in a few instances. On
palpation the fremitus is absent wherever the tumor reaches the chest
wall. If pulsating, it rarely has the forcible, heaving impulse of an aneu-
rismal sac. On auscultation there is usually silence over the dull region.
The heart-sounds are not transmitted and the respiratory murmur is feeble
or inaudible, rarely bronchial. Vocal resonance is, as a rule, absent. Sig-ns
of pleural effusion occur in a great many instances of mediastinal growth,
and if in any doubt the aspirator needle should be used.
The diagnosis of mediastinal tumor from aneurism is sometimes ex-
tremely difficult. An interesting case reported and figured by Sokolosski,
in Bd. 19 of the Deutsches Arcliiv fiir klinische Medicin, in which
Oppolzer diagnosed aneurism and Skoda mediastinal tumor, illustrates
how in some instances the most skilful of observers may be unable to
agree. Scarcely a sign is found in aneurism which may not be duplicated
in mediastinal tumor. This is not strange, since the symptoms in both
are largely due to pressure. The time element is important. If a case
has persisted for more than eighteen months the disease is probably
aneurism. There are, however, exceptions to this. In the case of com-
pression of the vena cava mentioned above, the disease has lasted for more
than two years and the patient has improved so markedly under the use
of arsenic that had he no other lymphatic enlargements the diagnosis
might be uncertain. By far the most valuable sign of aneurism is the
diastolic shock so often to be felt, and in a majority of cases to be heard,
over the sac. This is rarely, if ever, present in mediastinal growths, even
when they perforate the sternum and have communicated pulsation. An-
other point of importance is that in a tumor, advancing from the medias-
tinum, eroding the sternum and appearing externally, if ancarismal, has
forcible, heaving, and distinctly expansile pulsations. The radiating pain
in the back and arms and neck is rather in favor of aneurism, as is also
a beneficial influence on it of iodide of potassium.
The frequency of pleural effusion in connection with mediastinal
tumor is to be constantly borne in mind. It may give curiously complex
characters to the physical signs — characters which are profoundly modi-
fied after as{)iration of the liquid.
(4) Abscess of the Mediastinum. — Hare collected 115 cases of medi-
astinal abscess, in 77 of wliich there were details sufficient to permit the
analysis. Of these cases the great majority occurred in males. Forty-four
580 DISEASES OF THE RESPIRATORY SYSTEM.
were instances of acute abscess. The anterior mediastinum is most com-
monly the seat of the suppuration. The cases are most frequently associated
with trauma. Some have followed erysipelas or occurred in association
with eruptive fevers. Many cases, particularly the chronic abscesses, are
of tuberculous origin. Of symptoms^ pain behind the sternum is the most
common. It may be of a throbbing character, and in the acute cases is
associated with fever, sometimes with chills and sweats. If the abscess is
large there may be dyspnoea. The pus may burrow into the abdomen,
perforate through an intercostal space, or it may erode the sternum. In-
stances are on record in which the abscess has discharged into the trachea
or oesophagus. In many cases, particularly of chronic abscess, the pus
becomes inspissated and produces no ill effect. The physical signs may
be very indefinite. A pulsating and fluctuating tumor may appear at the
border of the sternum or at the sternal notch. The absence of hruit^ of
the diastolic shock, and of the expansile pulsation usually enables a cor-
rect diagnosis to be made. When in doubt a fine hypodermic needle
may be inserted.
(5) Miscellaneous Affections. — In Hare's monograph there were 7 in-
stances of fibroma, 11 cases of dermoid cysts, 8 cases of hydatid cysts, and
cases of lipoma and gummata.
The thymus gland may be enlarged and produce the physical signs of
mediastinal tumor. In children there are instances of spasm of the glottis,
which is believed by some to depend upon enlargement of the thymus.
Jacobi,* in his monograph, says that some instances of sudden death and
also so-called thymic asthma may occasionally be referred to this cause.
Malignant tumors of the thymus may attain considerable size and produce
signs of tumor. In rare cases mediastinal growths develop from the thy-
roid gland. These may be substernal in position and directly connected
with the gland. Kretschy has reported a sarcoma of the thyroid four and
three quarter inches in length, which forms a mediastinal tumor passing
to the level of the ninth dorsal vertebra. I have reported a somewhat sim-
ilar instance, which developed in the left lobe of the thyroid and formed
an elongated mass which passed down beside the trachea to the bifurcation.
(6) Emphysema of the Mediastinum. — Air in the cellular tissues of
the mediastinum is met Avith in cases of trauma and occasionally in fatal
cases of diphtheria and in whooping-cough. Champneys has called atten-
tion to its frequency in tracheotomy, in which he says the conditions
favoring the production are division of the dee}") fascia, obstruction to the
air-passages, and inspiratory efforts. The deep fascia, he says, should not
be raised from the trachea. It is often associated with pneumothorax.
The condition seems by no means uncommon. Angel Money found it
in IG of 28 cases of tracheotomy, and in two of these pneumothorax also
was present.
* Transactions of the Association of American Physicians, vol. iii.
sectio:n' v.
DISEASES OF THE CIEOULATOEY SYSTEM.
I. DISEASES OF THE PEEICAEDIUM.
I. PERICARDITIS.
Pericaeditis is the result of infective processes, primary or secondary,
or arises by extension of inflammation from contiguous organs.
Etiology. — Primary^ so-called idiopathic, inflammation of this mem-
brane is rare ; but cases are met with, most commonly in children, in
which there is no evidence of rheumatism or other conditions with which
the disease is usually associated.
Pericarditis from injury usually comes under the care of the surgeon
in connection with the primary wound. Interesting cases are those in
which the traumatism is from within, due to the passage of some foreign
body — such as a needle, a pin, or a bone — through the oesophagus into the
pericardium.
As a secondary process pericarditis is met with in the following affec-
tions : (a) A majority of the cases occur in connection with rheumatism.
The percentage given by different authors ranges from thirty to seventy.
The articular trouble may be slight or, indeed, the disease may be asso-
ciated with acute tonsillitis of rheumatic subjects. Cases are recorded in
which the pericarditis has preceded the articular disease, {h) Septic
processes rank next to rheumatism. In the acute necrosis of bone and
puerperal fever it is not uncommon, (c) Tuberculosis, in which the dis-
ease may be primary or part of a general involvement of the serous sacs
or associated with extensive pulmonary disease, {d) Eruptive fevers. In
children, the disease is not infrequent after scarlatina. It is rarely met
with in measles, small- pox, or typhoid fever. In other infective diseases,
such as diphtheria and pneumonia, it is rare, (e) Dyscrasias. Certain
altered conditions of the system seem to render the pericardium more
susceptible to inflammation. Of tliese gout takes the first place. In
chronic Ikight's disease pericarditis is by no means rare. The pericar-
dite hriyhtUiuG of the French forms one of the most important groups
of the disease in persons over fifty years of age, most frequently accom-
582 DISEASES OF THE CIRCULATORY SYSTEM.
panying the chronic interstitial form. Pericarditis has been met with also
in scurvy and diabetes.
Pericarditis by extension of disease from contiguous organs. In pleuro-
pneumonia it forms one of the most serious complications, and was pres-
ent in 5 cases in 100 post-mortems in this disease which I made at the
Montreal General Hospital. It is most often met with in the pleuro-
pneumonia of children and of alcoholics. The association with simple
pleurisy is much less common. In ulcerative endocarditis, purulent myo-
carditis, and in aneurism of the aorta pericarditis is occasionally found.
It may also result from extension of disease from the bronchial glands,
the ribs, sternum, vertebrae, and even from the abdominal viscera.
Pericarditis occurs at all ages. Cases are reported in the foetus. In
the new-born it may result from septic infection througli the navel.
Througliout childhood the incidence of rheumatism and scarlet fever
makes it a frequent affection, whereas late in life it is most often asso-
ciated with Bright's disease and gout. Males are somewhat more fre-
quently attacked than females. Climatic and seasonal influences have
been mentioned by some writers. The so-called epidemics of pericar-
ditis have been outbreaks of pneumonia with this as a frequent compli-
cation.
Anatomically as well as clinically the disease may be considered under
the folloAving divisions :
1. Acute, plastic, or dry pericarditis.
2. Pericarditis with effusion — sero-fibrinous, haemorrhagic, or purulent.
3. Chronic adhesive pericarditis (adherent pericardium).
Acute Plastic Pericarditis. — This, the most common form, occurs
usually as a secondary process, and is distinguished by the small amount
of fluid exudation, which does not, as in the next variety, give special
characters to the disease. It is a benign form and rarely, if ever, of itself
proves fatal.
Anatomically it may be partial or general. In the mildest grades the
serous membrane looks lustreless and roughened. This is due to the
presence of a thin fibrinous sheeting, which can be lifted with the knife,
showing the membrane beneath to be injected or in places ecchymotic.
As the fibrinous sheeting increases in thickness the constant movement
of tlie adjacent surfaces gives to it sometimes a ridge-like, at others a
honeycombed appearance. With more abundant fibrinous exudation the
membranes present an appearance resembling buttered surfaces which
have been drawn apart. The fibrin is in long shreds, and the heart pre-
sents a curiously shaggy appearance — the so-called hairy heart of old
writers — cor villosum.
In mild grades the subjacent muscle looks normal ; but in the more
prolonged and severe cases there is myocarditis, and for 2 or 3 mm.
beneath the visceral layer the muscle presents a pale, turbid appearance.
PERICARDITIS. 583
Many of these acute cases are tuberculous ; covered by the layers of lymph
the granulations are easily overlooked in a superficial examination.
Slight fluid exudation is invariably present, entangled in the meshes
of fibrin, but there may be very thick fibrinous layers without much
serous effusion.
Symptoms. — The majority of cases of simple plastic pericarditis,
like simple endocarditis, present no symptoms, and unless sought for there
are no objective signs indicating its existence. In the post-mortem room
it is not uncommon to find it in cases in which its presence has been un-
suspected during life.
Pain is a variable symptom, not usually intense, and in this form
rarely excited by pressure. It is more marked in the early stage, and may
be referred either to the praecordia or to the region of the xiphoid carti-
lage. Instances are recorded of pain of an aggravated and most distress-
ing character resembling angina. Fever is usually present, but it is not
always easy to say how mach depends upon the primary febrile affection,
and how much upon the pericarditis. It is as a rule not high, rarely
exceeding 102-5°. In rheumatic cases hyperpyrexia has been observed.
Physical Signs. — Inspection is negative ; palpation may reveal the pres-
ence of a distinct fremitus caused by the rubbing of the roughened peri-
cardial surfaces. This is usually best marked over the right ventricle. It
is not always to be felt, even when the friction sound on auscultation is
loud and clear. Auscultation : The friction sound, due to the movement
of the pericardial surfaces upon each other, is one of the most distinctive
of physical signs. It is double, corresponding to the systole and diastole ;
but the synchronism with the heart-sounds is not accurate, and the to-and-
fro murmur usually outlasts the time occupied by the first and second
sound. In rare instances the friction is single ; more frequently it ap-
pears to be triple in character — a sort of canter rhythm. The sounds have
a peculiar rubbing, grating quality, characteristic when once recognized,
and rarely simulated by endocardial murmurs. Sometimes instead of
grating there is a creaking quality— the bruit de cuir neuf— the new-
leather murmur of the French. The pericardial friction appears super-
ficial, very close to the ear, and is usually intensified by pressure with the
stethoscope. It is best heard over the right ventricle, the part of the heart
which is most closely in contact with the front of the chest— that is, in the
fourth and fifth interspaces and adjacent portions of the sternum. There
are instances in which the friction is most marked at the base over the
aorta and at the superior reflection of the pericardium. Occasionally it
is best heard at the apex. It may be limited and heard over a very narrow
area, or it may be transmitted up and down the sternum. There are,
however, no definite lines of transmission as in the endocardial murmur.
An important point is the variability of sounds, both in position and
quality; tliey may be heard at one visit and not at another. The maxi-
mum of intensity will be found to vary with position.
584: DISEASES OF THE CIRCULATORY SYSTEM.
Diagnosis. — There is rarely any difficulty in determining the pres-
ence of a dry pericarditis, for the friction sounds are distinctive. The
double murmur of aortic incompetency may simulate closely the to-and-
fro pericardial rub. I recall one instance at least in which this mistake
was made. The constant character of the aortic murmur, the direction
of transmission, the phenomena in the arteries, and the associated condi-
tions of the disease should be sufficient to prevent this error.
I have never known an instance in which pericarditis was mistaken for
endocarditis, though writers refer to such, and give the differential diag-
nosis in the two affections. The only possible mistake could be made in
those rare instances of single soft, systolic, pericardial friction.
Pleuro-pericardial friction is very common, and may be associated with
endo-pericarditis, particularly in cases of pleuro-pneumonia. It is fre-
quent, too, in phthisis. It is best heard over the left border of the heart,
and is much affected by the respiratory movement. Holding the breath
or taking a deep inspiration may annihilate it. The rhythm is not the sim-
ple to-and-fro diastolic and systolic, but the respiratory rhythm is super-
added, usually intensifying the murmur during expiration and lessening
it on inspiration. In phthisis there are instances in which, with the fric-
tion, a loud systolic click is heard, due to the compression of a thin layer
of lung and the expulsion of a bubble of air from a small softening focus
or from a bronchus.
Course and Termination. — Simple fibrinous pericarditis never kills,
but it occurs so often in connection with serious affections that we have
frequent opportunities to see all^ stages of its progress. In the majority
of cases the inflammation subsides and the thin fibrinous laminae gradually
become converted into connective tissue, which unites the pericardial leaves
firmly together. In other instances the inflammation progresses, with in-
crease of the exudation, and the condition is changed from a " dry " to a
" moist " pericarditis, or the pericarditis with effusion.
In a few instances— probably always tuberculous— the simple plastic
pericarditis becomes chronic, and great thickening of both visceral and
parietal layers is gradually induced.
Pericarditis with Effusion.— Though commonly a direct sequence of
the dry or plastic pericarditis, of which it is sometimes spoken as the sec-
ond stage, this form presents special features and deserves separate con-
sideration. It is found most frequently in association with acute rheuma-
tism, tuberculosis, and septicemia, and sets in usually with the symptoms
above described, namely, precordial pain, with slight fever or a distinct
chill.
In children the disease may, like pleurisy, come on without local symp-
toms, and, after a week or two of failing health, slight fever, shortness of
breath, and increasing pallor, the physician may find, to his astonishment,
signs of most extensive pericardial effusion. These latent cases are often tu-
PERICARDITIS. 585
berculous. The effusion may be sero-fibrinous, haemorrhagic, or purulent.
The amount varies from 200 or 300 c. c. to 2 litres. In the cases of sero-
fibrinous exudation the pericardial membranes are covered with thick,
creamy fibrin, which may be in ridges or honeycombed, or may present
long, villous extensions. The parietal layer may be several millimetres in
thickness and may form a firm, leathery membrane. The haemorrhagic
exudation is usually associated with tuberculous, or with cancerous peri-
carditis, or with the disease in the aged. The lymph is less abundant,
but both surfaces are injected and often show numerous haemorrhages.
Thick, curdy masses of lymph are usually found in the dependent part of
the sac. In the purulent effusion the fluid has a creamy consistency, par-
ticularly in tuberculosis. In many cases the effusion is really sero-puru-
lent, a thin, turbid exudation containing flocculi of fibrin.
The pericardial layers are greatly thickened and covered with fibrin.
"When the fluid is pus, they present a grayish, rough, granular surface.
Sometimes there are distinct erosions on the visceral membrane. The
heart muscle in these cases becomes involved to a greater or less extent,
and on section, the tissue, for a distance of from two to three millimetres,
is pale and turbid, and shows evidence of fatty and granular change. En-
docarditis coexists frequently, but rarely results from the extension of the
inflammation through the wall of the heart.
Symptoms. — Even with copious effusion the onset and course may
be so insidious that no suspicion of the true nature of the disease is
aroused.
As in the simple pericarditis, pain may be present, either sharp and
stabbing or as a sense of distress and discomfort in the cardiac region.
It is more frequent with effusion than in the plastic form. Pressure
at the lower end of the sternum usually aggravates it. Dyspnoea is a
common and important symptom, one which, perhaps, more than any
other, excites suspicion of grave disorder and leads to careful examination
of heart and lungs. The patient is restless, lies upon the left side or, as
the effusion increases, sits up in bed. Associated with the dyspnoea is in
many cases a peculiarly dusky, anxious countenance. The pulse is rapid,
small, sometimes regular, and may present the characters known as pulsus
paradoxus, in which during each inspiration the pulse-beat becomes very
weak or is lost. These symptoms are due, in great part, to the direct
mechanical effect of the fluid within the pericardium which embarrasses
the heart's action. Other pressure effects are distention of the veins of
the neck, dysphagia, which may be a marked symptom, and irritative
cough from compression of the trachea. Aphonia is not uncommon, due
to compression or irritation of the recurrent laryngeal as it winds round
the aorta. Another important pressure effect is exercised upon the left
lung. In massive effusion the pericardial sac occupies such a large por-
tion of the antero-lateral region of the left side that the condition has fre-
quently been mistaken for pleurisy. Even in moderate grades the left
586 DISEASES OF THE CIRCULATORY SYSTEM.
lung is somewhat compressed. This is an additional element in the pro-
duction of the dyspnoea.
Great restlessness, insomnia, and in the later stages low delirium and
coma are symptoms in the more severe cases. Delirium and marked cere-
bral symptoms are associated with the hyperpyrexia of rheumatic cases,
but apart from the ordinary delirium there may be poculiar mental symp-
toms. The patient may become melancholic and show suicidal tendencies.
In other cases the condition resembles closely delirium tremens. Sibson,
who has specially described this condition, states that the majority of such
cases recover. Chorea may also occur, as was pointed out by Bright.
Epilepsy is a rare complication which has occurred, as in pleurisy, during
paracentesis.
Physical Signs. — Inspection. — In children the prsecordia bulges and
with copious exudation the antero-lateral region of the left chest becomes
enlarged. The intercostal spaces are prominent and there may be marked
oedema of the wall. Perforation externally through a space is very rare.
Owing to the compression of the lung, the expansion of the left side is
greatly diminished. The diaphragm and left lobe of the liver may be
pushed down and may produce a distinct prominence in the epigastric
region.
Palpation. — A gradual diminution and final obliteration of the cardiac
shock is a striking feature in progressive effusion. The apex beat is often
raised an interspace and dislocated outward. Alteration in the position
of the impulse simultaneously with the position of the patient, a sign
upon which Oppolzer laid great stress, cannot often be determined, as the
beat may, and usually does, disappear entirely. The pericardial friction
may lessen with the effusion, though it often persists at the base when
no longer palpable over the right ventricle, or may be felt in the erect
and not in the recumbent posture. Fluctuation can rarely, if ever, be
detected.
Percussion gives most important indications. The gradual distention
of the pericardial sac pushes aside the margins of the lungs so that a large
area comes in contact with the chest wall and gives a greatly increased
percussion dulness. The form of this dulness is irregularly pear-shaped ;
the base or broad surface directed downward and the stem or apex directed
upward toward the manubrium.
Auscultation. — The friction sound heard in the early stages may dis-
appear when the effusion is copious, but often persists at the base or at
the limited area of the apex. It may be audible in the erect and not in
the recumbent posture. AVith the absorption of the fluid the friction
returns. One of the most important signs is the gradual weakening of the
heart-sounds, which with the increase in the effusion may become so
muffled and indistinct as to be scarcely audible. The heart's action is
usually increased and the rhythm disturbed. Occasionally a systolic endo-
cardial murmur is heard.
PERICARDITIS. 587
Important accessory signs in large effusion are due to pressure on the
left lung. The antero-lateral margin of the lower lobe is pushed aside
and in some instances compressed, so that percussion in the axillary region,
in and just below the transverse nipple line, gives a modified percussion
note, usually a flat tympany. Variations in the position of the patient
may change materially this modified percussion area, over which on aus-
cultation there is either feeble or tubular breathing.
Course. — Cases vary extremely in the rapidity with which the effusion
takes place. In every instance, when a pericardial friction murmur has
been detected, the practitioner should immediately outline with care-
using the aniline pencil or nitrate of silver— the upper and left limits of
cardiac dulness, since he will in this way have certain positive guides in
determining the rate and grade of the effusion. In many instances the
exudation is slight in amount, reaches a maximum within forty-eight
hours, and then gradually subsides. In other instances the accumulation
is more gradual and progressive, increasing for several weeks. To such
cases the term chronic has been applied. The rapidity with which a sero-
fibrinous effusion may be absorbed is surprising. The possibility of the
absorption of purulent exudate is shown by the cases in which the peri-
cardium contains semi-solid grayish masses in all stages of calcification.
With sero-fibrinous effusion, if moderate in amount, recovery is the rule,
with inevitable union, however, of the pericardial layers. In some of the
septic cases there is a rapid formation of pus and a fatal result may follow
in three or four days. More commonly, when death occurs with large
effusion, it is not until the second or third week and takes place by grad-
ual asthenia.
Prognosis. — In the sero-fibrinous effusions the outlook is good, and
a large majority of all the rheumatic cases recover. The purulent effu-
sions are, of course, more dangerous ; the septic cases are usually fatal,
and recovery is rare in the slow, insidious tuberculous forms.
Diagnosis. — Probably no serious disease is so frequently overlooked
by the practitioner. Post-mortem experience shows how often pericarditis
is not recognized, or goes on to resolution and adhesion without attract-
ing notice. In a case of rheumatism, watched from the outset, with the
attention directed daily to the heart, it is one of the simplest of diseases
to diagnose ; but when one is called to a case for the first time and finds
perhaps an increased area of precordial dulness, it is often very hard to
determine with certainty whether or not effusion is present.
The difficulty usually lies in distinguishing between dilatation of the
heart and pericardial effusion. Although the differential signs are simple
enough on paper, it is notoriously difficult in certain cases, particularly in
stout persons, to say which of the conditions exists. The points which
deserve attention are :
{a) 'J'he character of impulse, whi(;h in dilatation, particularly in thin-
clie:;ted people, is commonly visible and wavy.
38
588 DISEASES OF THE CIRCULATORY SYSTEM.
(b) The shock of the cardiac sounds is more distinctly palpable in
dilatation.
(c) The area of dulness in dilatation rarely has the triangular form ;
nor does it, except in cases of mitral stenosis, reach so high along the left
sternal margin or so low in the fifth and sixth interspaces without visible
or palpable impulse. An upper limit of dulness shifting with the posi-
tion speaks strongly for effusion.
(d) In dilatation the heart-sounds are clearer, often sharp, valvular,
or foetal in character; whereas in effusion the sounds are distant and
muffled.
(e) Rarely in dilatation is the distention sufficient to compress the
lung and produce the tympanitic note in the axillary region.
The number of excellent observers Avho have acknowledged that they
have failed sometimes to discriminate between these two conditions, and
who have indeed performed paracentesis cordis instead of paracentesis
pericardii, is perhaps the best comment on the difficulties which certain
cases present.
Massive (1| to 2 litre) exudations have been confounded with a pleu-
ral effusion. On more than one occasion the pericardium has been
tapped under the impression that the exudate was pleuritic. The flat
tympany in the infrascapular region, the absence of well-defined movable
dulness, and the feeble, muffled sounds are indicative points. If the case
has been followed from day to day there is rarely much difficulty ; but it
is different when a case presents a large area of dulness in the antero-
lateral region of the left che^fc, and there is no to-and-fro pericardial
friction murmur. Many of the cases have been regarded as encapsulated
pleural effusion.
The nature of the fluid cannot positively be determined without aspi-
ration ; but a fairly accurate opinion can be formed by the nature of the
primary disease and the general condition of the patient. In rheumatic
cases the exudation is usually sero-fibrinous ; in septic and tuberculous
cases it is often purulent from the outset ; in senile, nephritic, and tuber-
culous cases the exudation is sometimes haemorrhagic.
Treatment. — The patient should have absolute quiet, mentally and
bodily, so as to reduce to a minimum the heart's action. Drugs given for
this purpose, such as aconite or digitalis, are of doubtful utility. Local
bloodletting by cupping or leeches is certainly advantageous in robust
subjects, particularly in the cases of extension in pleuro-pneumonia. The
ice-bag or Leiter's tube may be used to advantage. They have the double
effect of reducing the heart's action and retarding the progress of inflam-
mation. Blisters are not indicated in the early stage.
When effusion is present, the following measures to promote absorp-
tion may be adopted : Blisters to the prcTcordia, a practice not so much
in vogue now as formerly. It is surprising, however, in some instances,
how quickly an effusion will subside on their application. If the patient's
PERICARDITIS. 589
strength is good, a purge every other morning may be given. The diet
should be light, dry, and nutritious. In cases in which the pulse is strong
and the constitutional disturbance not great, iodide of potassium may be
of service, and the action of the kidneys may be promoted by the infusion
of digitalis and acetate of potash.
When the effusion is large, as soon as signs of serious impairment of
the heart occur, as indicated by dyspnoea, small rapid pulse, dusky, anxious
countenance, surgical measures should be resorted to, and paracentesis, or
incision of the pericardium, at once be performed. With the sero-fibrin-
ous exudate, such as commonly occurs after rheumatism, aspiration is
sufficient ; but when the exudate is purulent the pericardium should be
freely incised and freely drained. The puncture may be made in the
fourth interspace, either at the left sternal margin or 2*5 cm. (an inch)
from it. If made in the fifth interspace it is well to puncture an inch
and a half from the left sternal margin. In large effusions the pericar-
dium can also be readily reached without danger by thrusting the needle
upward and backward close to the costal margin in the left costo-xiphoid
angle. The results of paracentesis of the pericardium have so far not
been satisfactory. With an earlier operation in many instances and a
more radical one in others — a free incision and not aspiration w^hen the
fluid is purulent — the percentage of recoveries will be greatly increased.
Chronic Adhesive Pericarditis {Adherent Pericardium). — This con-
dition follows acute pericarditis, and may be partial or universal. It is
not very uncommon to meet with limited synechia over the right ven-
tricle. In the mildest grades of complete adhesion the amount of con-
nective tissue between the membranes is slight, and there is not much
thickening. These are the instances which follow the fibrinous rheu-
matic pericarditis. The most extreme thickening of the membranes is
met with in the chronic tuberculous form, which has already been de-
scribed, and which is much more common than indicated in the litera-
ture. After the absorption of an extensive purulent or sero-purulent
exudate the inspissated remnants may undergo calcification. This may
be in quite a limited region, most frequently over the auricles or at the
base of the heart. In extreme grades the organ is completely invested
by a calcareous membrane, which in places may be from 1 to 1-5 cm. in
tliickness.
The symptoms of adherent pericardium are uncertain and indefinite.
A majority of the cases are met with accidentally in the post-mortem
room, and there may have been no indications whatever during life of
cardiac disturbance. Enlargement of the heart is an almost constant ac-
companiment of universal adhesion, and many of the cases come under
observation for the first time with failure of this hypertrophy and signs
of cardiac insufficiency.
The following are the important points in the diagnosis :
(1) Inspection. — In children, in whom the condition is not very un-
590 DISEASES OF THE CIRCULATORY SYSTEM.
common as a sequence of rheumatism, the hypertrophied heart causes bulo--
ing of the chest wall. The area of cardiac impulse is increased and may
sometimes be seen from the third to the sixth interspace and beyond the
nipple line. The strongest impulse may be to the right of the apex. The
wavy character of the pulsation in the third, fourth, and fifth interspaces
is not peculiar to adherent pericardium. Not much stress can be laid
upon the fixed position of the impulse, which in great enlargement of the
heart is not much infiuenced either by posture or respiration. A more
important point is systolic retraction of the apex region. Whether this
occurs without adhesion of the pericardium to the chest wall is doubtful.
It is often marked, and is sometimes best appreciated by the application
of the hand over the apex region, which is felt to be drawn in at the mo-
ment of systole. The retraction may be most noticeable in the lower
sternal region or even at the xiphoid cartilage. Following this there is
sometimes a rapid rebound— the diastolic shock— which has been regarded
by some as the most reliable of all signs of pericardial adhesion. Asso-
ciated with this diastolic rebound is the so-called Friedricli's sign— dias-
tolic collapse of the cervical veins.
(2) Percussion reveals an increase in the area of cardiac dulness, par-
ticularly upward as high as the second interspace. In a majority of the
cases there are adhesions as well between the pleura and pericardium — in
ten of thirteen cases analyzed by Ord. In some instances the dulness may
reach as high as the first interspace. A sign of value is the fixed limit
above and to the left of cardiac dulness, as pointed out by C. J. B. Will-
iams. When the outer layer of"*the pericardium is adherent to the pleura
this is a sign of very definite value, and the limit of dulness varies very
slightly on deep inspiration.
(3) On auscultation the phenomena vary extremely with the condition
of the chambers. There may be no murmurs. When extreme dilatation
is present the gallop or foetal rhythm occurs. A loud regurgitant mur-
mur is not uncommon at the apex region, and the cases are frequently
mistaken for mitral insufficiency.
(4) The pulsus paradoxus in which during inspiration the pulse-
wave is small and feeble, is sometimes present, but it is not a diagnostic
sign of either simple pericardial adhesion or of the cicatricial mediastino-
pericarditis.
Adherent pericardium with extreme dilatation of tlie heart may raise
the suspicion of pericarditis with effusion, as the outline of dulness in both
is somewhat alike. As a rule, however, the basic dulness is broader in ad-
hesion, and has not the pear-shaped outline. The extent and wavy char-
acter of the impulse is never so marked in large effusions, and the heart-
sounds are muffled.
OTHER AFFECTIONS OF THE PERICARDIUM. 591
II. OTHER AFFECTIONS OF THE PERICARDIUM.
1. Hydropericardium. — Naturally there are in the pericardial sac a
few cubic centimetres of clear, citron-colored fluid, which probably repre-
sents a post-mortem transudate. In certain conditions during life there
may be large secretions of serum forming what is known as dropsy of the
pericardium. It occurs usually in connection with general dropsy, due
to kidney or heart disease ; more commonly the former. It rarely of it-
self proves fatal, though when the effusion is excessive it adds to the
embarrassment of the heart and the lungs, particularly when the pleural
cavities are the seat of similar exudation. There are rare instances in
which effusion into the pericardium occurs after scarlet fever with few,
if any, other dropsical symptoms. The physical signs are those already
referred to in connection with pericarditis with effusion. It is frequently
overlooked.
In rare cases the serum has a milky character — chylo-pericardium.
2. HsBino-pericardillin. — This condition, by no means uncommon, is
met with in aneurism of the first part of the aorta, of the cardiac wall, or
of the coronary arteries, and in rupture and wounds of the heart. Death
usually follows before there is time for the production of symptoms other
than those of rapid heart-failure due to compression. Particularly is this
the case in aneurism. In rupture of the heart the patient may live for
many hours or even days with symptoms of progressive heart-failure,
dyspnoea, and the physical signs of effusion.
As already mentioned, the inflammatory exudate of tubercle or cancer
is often blood-stained. The same is true of the effusion in the peri-
carditis of Bright's disease and of old people.
3. Pneumo-pericardium. — Gas is rarely found in the pericardial sac,
and is due, as a rule, to perforation from without, as in the case of stab
wounds, or the result of perforation from the lungs, oesophagus, or
stomach. Possibly, too, it may result from the decomposition of a puru-
lent exudate. As a result of perforation, acute pericarditis is always ex-
cited, and the effusion rapidly becomes purulent. The physical signs are
remarkable. When the effusion is copious the fluid and gas together give
a movable area of percussion dulness with marked tympany in the region
of the gas. On auscultation, remarkable splashing, churning, metallic
plienomena are heard with friction and possibly feeble, distant heart-
sounds. Death follows rapidly, even in thirty-six hours, as in a case (the
only one which I have seen) of perforation of the pericardium in cancer
of the stomach. Except as a result of injury, the condition is not one for
which treatment is available. In a case of perforation from without with
signs of effusion, to enlarge the wound by free incision would be justi-
fiable.
592 DISEASES OF THE CIliCULATORY SYSTEM.
11. DISEASES OF THE IIEAET.
I. ENDOCARDITIS.
Inflammation of the lining membrane of the heart is usually confined
to the valves, so that the term is practically synonymous with valvular
endocarditis. It occurs in two forms — acute^ characterized by the pres-
ence of vegetations with loss of continuity or of substance in the valve
tissues ; chronic^ a slow sclerotic change, resulting in thickening, pucker-
ing, and deformity.
Acute Endocarditis.
This occurs in rare instances as a primary, independent affection ; but
in the great majority of cases it is an accident in various infective pro-
cesses, so that in reality the disease does not constitute an etiological
entity.
For convenience of description we speak of a simple or benign, and a
malignant or ulcerative endocarditis, between which, however, there is no
essential anatomical difference, as all gradations can be traced, and they
represent but different degrees of intensity of the same process.
Simple Endocarditis. — This is characterized by the presence on the
valves or on the lining membrane of the chambers of minute vegetations,
ranging from 1 to 4 mm. in size, with an irregular and fissured surface,
giving to them a warty or verrucose appearance. Often these little cauli-
flower-like excrescences are attached by very narrow pedicles. It is rare
to see any swelling or infiltration of the endocardium in the neighborhood
of even the smallest of the granulations, and although small capillary
vessels do exist at the edges of the valves, redness, indicative of the injec-
tion or distention of the vessels, is extremely rare. With time the vegeta-
tions may increase greatly in size, but in what may be called simple
endocarditis the size rarely exceeds that mentioned above. The finer
changes in the process consist of the proliferation of the subendothelial
connective-tissue elements, resulting in a small-celled infiltration. What
part, if any, the endothelial cells play in this is not accurately known.
The superficial elements undergo a coagulation necrosis, and fibrin is
deposited from the blood, often in layers. Practically a vegetation is a
small area of granulation tissue capped with fibrin. Micro-organisms
are present, entangled in the granular and fibrillated fibrin, but whether
they constitute an essential and constant element in all cases of simple
endocarditis has not yet been decided.
The further clianges in the vegetation may be either in the direction
of increased proliferation of the connective-tissue elements of the valve,
forming an extensive area of necrosis and the production of the condition
which, from its more intense grade, we speak of as malignant or ulcerative
endocarditis ; or, as is more usual, healing occurs. The vegetation is
ENDOCARDITIS. 593
absorbed, and there remains a small nodular thickening of the valve. A
third possibility is the dislocation of a vegetation with transference as an
embolus to a distant part of the circulation. It is to be noted, however,
that this untoward event is rare in acute endocarditis associated with
febrile affections, whereas it is by no means uncommon in the simple
endocarditis which occurs so constantly on old sclerotic valves.
Anatomically, in the majority of instances of acute endocarditis, cica-
trization of the granulation tissue takes place in time, with but little
damage to the valve beyond slight nodular thickening. The essential
danger is remote and results from the slow changes in the valve tissue,
which are so apt to follow an acute inflammation. AYhy this should be
so cannot at present be explained ; but the fact remains that the simple
endocarditis, harmless in itself, such as we meet with in rheumatism or
in chorea, lays the foundation of subsequent organic lesions, owing to the
initiation of nutritive changes leading to sclerosis with contraction and
deformity.
Endocarditis is much more common on the left side of the heart and
involves the valvular endocardium in the great majority of cases. During
foetal life the right side of the heart is often affected. The chordae ten-
dineae are sometimes involved with the valves, rarely alone. The mitral
valves are more often affected than the aortic. On the mitral segment
the vegetations are usually on the auricular face, not at the margin, but
at a distance of 2 or 3 mm., forming a row of bead-like outgrowths. So,
too, on the aortic segment they are not seen on the free margin, but just
below, on the ventricular face, following the margin of the so-called lunat-
ed spaces. In both the valves this peculiar distribution follows, as Sibson
suggests, the lines of maximum contact.
Etiology. — Simple endocarditis does not constitute a disease of it-
self, but is invariably found with some other affection. The general ex-
perience of the profession has confirmed the original observation of Bouil-
laud as to the frequency of association of simple endocarditis with acute
articular rheumatism. Possibly it is nothing in the disease itself, but
simply an altered state of the fluid media — a reduction perhaps of the
lethal influences which they normally exert — permitting the invasion of
the blood by certain micro-organisms. Tonsillitis, which in some forms
is regarded as a rheumatic affection, may be complicated with endocardi-
tis. Of the specific diseases of childhood it is not uncommon in scarlet
fever, while it is rare in measles and chicken-pox. In diphtheria simple
endocarditis is rare. It was not present in a single instance of 30 autop-
sies which I made in this disease at the Montreal General Hospital. In
small-pox it is not common. It is stated to be more frequent in typhoid
fever but was not present in 65 post-mortems in this disease.
In pneumonia both simple and malignant endocarditis are common.
In 100 autopsies in this disease made at the Montreal General Hospital
there were 5 instances of the former. Acute endocarditis is by no
594 DISEASES OF THE CIRCULATORY SYSTEM.
means rare in phthisis. I have met with it in 12 cases in 216 post-mor-
tems.
In cliorea simple warty vegetations are found on the valves in a large
majority of all fatal cases. There is no disease in which, post mortem,
acute endocarditis has been so frequently found. And lastly, simple
endocarditis is met with in diseases associated with loss of flesh and pro-
gressive debility, as cancer, and such disorders as gout, diabetes, and
Bright's disease.
A very common form is that which occurs on the sclerotic valves in
old heart-disease — the so-called recurring endocarditis.
Symptoms. — Neither the clinical course nor the physical signs are in
any respect characteristic. The great majority of the cases are latent and
there is no indication whatever of cardiac mischief. Experience has taught
us that endocarditis is frequently found post mortem in persons in whom
it was not suspected during life. There are certain features, however, by
which its presence is indicated with a degree of probability. The patient,
as a rule, does not complain of any pain or cardiac distress. In a case of
acute rheumatism, for example, the symptoms to excite suspicion would
be increased rapidity of the heart's action, perhaps slight irregularity, and
an increase in the fever without aggravation of the joint trouble. Kows
of tiny vegetations on the mitral or on the aortic segments seem a trifling
matter to excite fever and it is difficult in the endocarditis of febrile pro-
cesses to say definitely in every instance that an increase in the fever de-
pends upon the endocardial complication. But a study of the recurring
endocarditis — which is of the warty variety, consisting of minute beads on
old sclerotic valves— shows that this process may be associated, for days
or weeks at a time, with slight fever ranging from 100° to 102|°. Pal-
pitation may be a marked feature and is a symptom upon which certain
authors lay great stress.
The diagnosis of the condition rests upon physical signs which are
notoriously uncertain. The presence of a murmur at one or other of the
cardiac areas in a case of fever is often regarded as indicative of the exist-
ence of endocarditis. This extremely common mistake has arisen from
the fact that the bruit de souffle or bellows murmur is common to endo-
carditis and a number of other conditions which have nothing to do with
it. At first there may be only a slight roughening of the first sound,
which may gradually develop into a distinct murmur. Taken alone, it is,
however, a very uncertain and fallacious sign.
Malignant Endocarditis. — Acute endocarditis of a malignant character
is met with :
{a) As a primary disease of the lining membrane of the heart or of
its valves.
(h) As a secondary affection in acute rheumatism, pneumonia, and in
various specific fevers ; or as an associated condition in septic processes.
ENDOCARDITIS. 595
It is also known by the names of ulcerative, infectious, or diphtheritic
endocarditis, but the term malignant seems most appropriate to charac-
terize the essential clinical features of the disease.
Etiology. — The existence of a primary endocarditis has been doubted ;
but there are instances in which persons previously in good health, without
any history of affections with which endocarditis is usually associated, have
been attacked with symptoms resembling severe typhus or typhoid. In
one case which I saw death occurred on the sixth day and no lesions were
found other than those of malignant endocarditis.
Rheumatism, with which simple endocarditis is frequently associated,
is not so often complicated with the malignant form. Thus, in only
24 of 209 cases the symptoms of severe endocarditis arose in the progress
of acute or subacute rheumatism. In only 3 of the Montreal cases was
there a history of rheumatism either before or during the attacks.
Malignant endocarditis is extremely rare in chorea. Of all acute dis-
eases complicated with severe endocarditis pneumonia probably heads the
list. This fact, which had been referred to by several of the older writers,
was brought out in a striking manner by the figures on which my lectures
were based. In 11 of the 23 Montreal cases the disease came on with
lobar pneumonia, while it developed with this disease in 54 of the 209
cases analyzed — indeed, the endocarditis which occurs in pneumonia seems
to be of an unusually malignant type, as in 16 cases of my 100 autopsies
in this disease in which this lesion was present, 11 were of this form.
Meningitis was associated with endocarditis in 25 of the 209 cases, and in
15 there was also pneumonia.
The affection may complicate erysipelas, septicaemia (from whatever
cause), and puerperal fever and gonorrhoea. Malignant endocarditis is
very rare in tuberculosis, typhoid fever, and diphtheria.
It has been stated by many writers that endocarditis occurs in ague.
With the unusual facilities for the study of this disease which I have had
in the past seven years I have not yet met with an instance. Unquestion-
ably, in the majority of these cases, the intermittent pyrexia, which has
been regarded as characteristic of the ague, has depended upon the endo-
carditis. In dysentery cases have been described. In small-pox and
scarlet fever, with which simple endocarditis is not infrequently compli-
cated, the malignant form is extremely rare.
Morbid Anatomy. — The lesions may be either vegetative, ulcera-
tive, or suppurative, and these forms may occur alone or in combination.
Even with vegetations there is distinct necrosis and loss of the endocardial
substance. More frequently there is ulceration, either superficial, involv-
ing only the endocardium, or deep and distinct, leading to perforation of
a valve, of a septum, or even of the heart itself. In the suppurative form
the deeper tissues of the valve appear first affected and small abscesses are
found at the bases of the vegetations. The vegetations may present a re-
markable greenish-gray or greenish-yellow color, and when of long stand-
596 DISEASES OF THE CIRCULATORY SYSTEM.
ing, or even in cases which from the clinical history appear to be tolerably
acute, the vegetations may be crusted with lime salts.
A large vegetation of malignant endocarditis consists histologically of
a granular and fibrillated fibrin, colonies of micro-organisms, and distinct
granulation tissue at the base, while the subjacent endocardial layers
show infiltration and proliferation. The destruction of tissue results from
a gradual extension of the necrotic processes. Various micro-organisms
have been found in connection with the disease, and the following brief
statement may be made with reference to them : In a large proportion of
the cases streptococci and staphylococci are found. The pneumococcus
has been cultivated from the vegetations in pneumonia. Other forms
have occasionally been met with.
The following figures, taken from my Gulstonian lectures at the Royal
College of Physicians, give an approximate estimate of the frequency with
which in 209 cases different parts of the heart were affected : Aortic and
mitral valves together, 41 ; aortic valves alone, 53 ; mitral valves alone, 77 ;
tricuspid in 19 ; the pulmonary valves in 15 ; and the heart wall in 33.
In 9 instances the right heart alone was involved.
Mural endocarditis is seen most often at the upper part of the septum
of the left ventricle. Next in order is the endocarditis of the left auricle
on the postero-external wall. The ulcerative changes may lead to perfora-
tion of a valve segment, erosion of the chordae tendinese, perforation of
the septum, or even of the heart itself. A common result of the ulcera-
tion is the production of valvular aneurism. In three fourths of the cases
the affected valves present old sclerotic changes. The process may extend
to the aorta, producing, as in one of my cases, extensive endarteritis with
multiple acute aneurisms.
The associated pathological changes are partly those of the primary
disease to which the endocarditis is secondary and partly those due to
embolism. In the endocarditis of septic processes there is the local lesion
— an acute necrosis, a suppurative wound, or puerperal disease. In many
cases the lesions are those of pneumonia, rheumatism, or other febrile pro-
cesses. The changes due to embolism constitute the most striking feat-
ures, but it is remarkable that in some instances, even with endocarditis
of a markedly ulcerative character, there may be no trace of embolic
processes.
The infarcts may be few in number— only one or two, perhaps, in the
spleen or kidney — or they may exist in hundreds throughout the various
parts of tlie body. They may present the ordinary appearance of red or
white infarcts of a suppurative character. They are most common in the
spleen and kidneys, though they may be numerous in the brain, and in
many cases are very abundant in the intestines. In right-sided endocar-
ditis there may be infarcts in the lungs. In many of the cases there are
innumerable miliary abscesses. Acute suppurative meningitis was met
with in 5 of 23 of the Montreal cases, and in over ten per cent of the 209
ENDOCARDITIS. 597
cases analyzed in the literature. Acute suppurative parotitis also may
occur.
Symptoms. — It is difficult to give a satisfactory clinical picture of
the disease because the modes of onset are so varied and the symptoms so
diverse. Arising in the course of some other disease, there may be simply
an intensification of the fever or a change in its character. In a ma-
jority of the cases there are present certain general features, such as irregu-
lar pyrexia, delirium, sweating, gradual failure of strength.
Embolic processes may give special characters, such as delirium, coma
or paralysis from involvement of the brain or its membranes, pain in the
sides and local peritonitis from infarction of the spleen, bloody urine from
implication of the kidneys, impaired vision from retinal haemorrhage, and
suppuration, and even gangrene, in various parts from the distribution of
the emboli.
Two special types of the disease have been recognized — the septic or
pyaemic and the typhoid. Other cases closely resemble true intermittent
fever. In some the cardiac symptoms are most prominent, while in others
again the main symptoms may be those of an acute affection of the cere-
bro-spinal system.
The septic type is met with usually in connection with an external
wound, the puerperal process, or an acute necrosis. There are rigors,
sweats, irregular fevers, and all of the signs of septic infection. The heart
symptoms may be completely masked by the general condition, and atten-
tion called to them only on the occurrence of embolism. In a most re-
markable sub-group of this type the disease may simulate a quotidian or a
tertian ague. The symptoms may develop in persons with chronic heart-
disease without any external lesions. These cases may be much prolonged
— for three or four months, or even longer, as in a case of Bristowe's.
The existence in some of these instances of a previous genuine malaria
has been a very puzzling circumstance.
The typhoid type is by far the most common and is characterized by
an irregular temperature, early prostration, delirium, somnolence, and
coma, relaxed bowels, sweating, which may be of a most drenching char-
acter, petechial and other rashes, and occasionally parotitis. The heart
symptoms may be completely overlooked, and in some intances the most
careful examination has failed to discover a murmur.
Under the cardiac group, as suggested by Bramwell, may be consid-
ered those cases in which patients with chronic valve disease are attacked
with marked fever and evidence of recent endocarditis. Many such cases
present symptoms of the pyaemic and typhoid character and may run a
most acute course. In others the process is less intense and the course
more chronic, lasting for weeks or months, so that the term acute is scarce-
ly applicable to them. In a case of this kind under the care of Mullin,
of Hamilton, tlie irregular fever lasted for more than a year. The autop-
sy showed extensive vegetative and ulcerative disease of the mitral valves.
598 DISEASES OF THE CIRCULATORY SYSTEM.
There are cases in which it is often difficult to decide whether
malignant endocarditis is present or not. Thus, a patient with aortic
valve disease is under treatment for failing compensation and begins to
have irregular fever with restlessness and cardiac distress ; embolic phe-
nomena may develop — sudden hemiplegia, pain in the region of the
spleen, or bloody urine, or perhaps peripheral embolism. There may be a
low delirium and the case may run a tolerably acute course ; but in other
instances the fever subsides and recovery occurs.
In what may be termed the cerebral group of cases the clinical pict-
ure may simulate a meningitis, either basilar or cerebro-spinal. There
may be acute delirium or, as in three of the Montreal cases, the patient
may be brought into the hospital unconscious. Heineman reports an in-
stance, with autopsy, in which the clinical picture was that of an acute
cerebro-spinal meningitis.
Certain special symptoms may be mentioned. The fever is not al-
ways of a remittent type, but may be high and continuous. Petechial
rashejs are very common and render the similarity very strong to certain
cases of typhoid and cerebro-spinal fevers. In one case the disease was
thought to be haemorrhagic small-pox. Erythematous rashes are not un-
common. The sweating may be most profuse, even exceeding that which
occurs in phthisis and ague. Diarrhoea is not necessarily associated with
embolic lesions in the intestines. Jaundice has been observed and cases
are on record which were mistaken for acute yellow atrophy.
The heart symptoms may be entirely latent and are not found unless a
careful search be made. Even on examination there may be no mur-
mur present. Instances are recorded by careful observers, in which the
examination of the heart has been negative. Cases with chronic valve
disease usually present no difficulty in diagnosis.
The course of the disease is varied, depending largely upon the nature
of the primary trouble. Except in the disease grafted upon chronic
valvulitis the course is rarely extended beyond five or six weeks. As
already mentioned, there are instances in which the disease is prolonged
for months. The most rapidly fatal case on record is described by
Eberth, the duration of which was scarcely two days.
Diagnosis.— In many cases the detection of the disease is very diffi-
cult; in others, with marked embolic symptoms, it is easy. From simple
endocarditis it is readily distinguished, though confusion occasionally
occurs in the transitional stage, when a simple is developing into a malig-
nant form. The constitutional symptoms are of a graver type, the fever
is higher, rigors are common, and septic and typhoid symptoms develop.
Perhaps a majority of the cases not associated with puerperal processes or
bone disease are confounded with typhoid fever. A differential diagnosis
may even be impossible, particularly when we consider that in typhoid
fever infarctions and parotitis may occur. The diarrhoea and abdominal
tenderness may also be present, which with the stupor and progressive
ENDOCARDITIS. 699
asthenia make a picture not to be distinguished from this disease. Points
which ma}^ guide us are : The more abrupt onset in endocarditis, tlio
absence of any regularity of the pyrexia in the early stage of the disease,
and the cardiac pain. Oppression and shortness of breath may be early
symptoms in malignant endocarditis. Rigors, too, are not uncommon.
Between pyaemia and malignant endocarditis there are practically no dif-
ferential features, for the disease really constitutes an arterial ])yaimia
(Wilks). In the acute cases resembling malignant fevers, the diagnosis is
usually made of typhus, typhoid, cerebro-spinal fever, or even of haemor-
rhagic small-pox. The intermittent pyrexia, occurring for weeks or
months, has led in some cases to the diagnosis of malaria, but this disease
could now be positively excluded by the blood examination.
The cases usually terminate fatally. The instances of recovery are
those more subacute forms, the so-called recurring endocarditis develop-
ing on old sclerotic valves in cases of chronic heart-disease.
Treatment. — We know no measures by which in rheumatism,
chorea, or the eruptive fevers the onset of endocarditis can be prevented.
As it is probable that many cases develop, particularly in children, in mild
forms of these diseases, it is well to guard the patients against taking cold
and insist upon rest and quiet, and to bear in mind that of all complica-
tions an acute endocarditis, though in its immediate effects harmless, is
perhaps the most serious. This statement is enforced by the observations
of Sibson that on a system of absolute rest the proportion of cases of
rheumatism attacked by endocarditis was less than of those who were not
so treated.
It is doubtful whether the salicylates in rheumatism have an influence
in reducing the liability to endocarditis. When the endocarditis is pres-
ent we know no remedies which will definitely influence the valvular
lesions. If there is much vascular excitement aconite may be given and
an ice-bag placed over the heart.
The salicylates are strongly advised by some writers and the sulpho-
carbolates have been recommended by Sansom. In the severer cases of
malignant endocarditis the treatment is practically that of septicaemia.
Chron^ic Endocarditis.
This condition, which is a sclerosis of the valve, may be primary, but is
oftener secondary to acute endocarditis, particularly the rheumatic form.
It is essentially a slow, insidious process which leads to deformity of the
valve segment and is the foundation of chronic valvular disease.
Certain poisons appear capable of initiating the change, such as alco-
hol, syphilis, and gout, though we are at present ignorant of the way in
which they act. A very important factor, particularly in tlie case of the
aortic valves, is the strain of prolonged and heavy muscular exertion. In
no other way can be explained the occurrence of so many cases of sclero-
600 DISEASES OF THE CIRCULATOHY SYSTEM.
sis of the aortic valves in young and middle-aged men whose occupations
necessitate the overuse of the muscles.
Morbid Anatomy. — Vegetations in the form in which they occur
in acute endocarditis are not present. In the early stage, which we
have frequent opportunities of seeing, the edge of the valve is a little
thickened and perhaps presents a few small nodular prominences, which
in some cases may represent the healed vegetations of the acute process.
In the aortic valves the tissue about the corpora Arantii is first affected,
producing a slight thickening with an increase in the size of the nodules.
The substance of the valve may lose its translucency, and the only change
noticeable is a grayish opacity and a slight loss of its delicate tenuity.
In the auriculo-ventricular valves these early changes are seen just within
the margin and here it is not uncommon to find swellings of a grayish-
red, somewhat infiltrated appearance, almost identical with the similar
structures on the intima of the aorta in arterio-sclerosis. Even early there
may be seen yellow or opaque-white subintimal fatty areas. As the scle-
rotic changes increase the fibrous tissue contracts and produces thickening
and deformity of the segment, the edges of which become round, curled,
and incapable of that delicate apposition necessary for perfect closure. A
sigmoid valve, for instance, may be narrowed one fourth or even one third
across its face, inducing the most extreme grade of insufficiency without
any special deformity and without any definite narrowing of the arterial
orifice. In the auriculo-ventricular segments a simple process of thicken-
ing and curling of the edges of the valves, inducing a failure to close
without forming any obstruction to the normal course of the blood-flow,
is less common. Still, we meet with instances at the mitral orifice, par-
ticularly in children, in which the edges of the valves are curled and
thickened, producing extreme insufficiency without any material narrow-
ing of the orifice. More frequently, as the disease advances, the chordae
tendineae become thickened, first at the valvular ends and then along
their course. The edges of the valves at their angles are gradually drawn
together and there is a definite narrowing of the orifice, leading in the
aorta to more or less stenosis and in the left auriculo-ventricular orifice —
the two most frequently involved — to constriction. Finally, in the scle-
rotic and necrotic tissues lime salts are dejiosited and may even reach the
deeper structures of the fibrous rings, and the entire valve becomes a
dense calcareous mass with scarcely a remnant of normal tissue. The
chordas tendineae may gradually become shortened, greatly thickened, and
in extreme cases the papillary muscles are implanted directly upon the
sclerotic and deformed valve. The apices of the papillary muscles usually
show marked fibroid change.
In all stages of the process the vegetations of simple endocarditis may
be found and upon sclerotic valves we find the severer, ulcerative form of
the disease.
Chronic 7nural endocarditis produces cicatricial-like patches of a gray-
ENDOCARDITIS. 601
ish-white appearance which are sometimes seen on the muscular trabecu-
lae of the ventricle or in the auricles. It often occurs in association with
myocarditis.
The frequency with which chronic endocarditis is met with may be
gathered from the following figures : In the statistics, amounting to from
12,000 to 14,000 autopsies, reported from Dresden, Wurzburg, and Prague
the percentage ranged from four to nine. The relative frequency of in-
volvement of the various valves is thus given in the collected statistics of
Parrot : The mitral orifice was involved in 621, the aortic in 380, the tri-
cuspid in 46, and the pulmonary in 11. This gives 57 instances in the
right to 1,001 in the left heart.
The endocarditis of the foetus is usually of the sclerotic form and in-
volves the valves of the right more frequently than those of the left side.
The effects of sclerotic endocarditis are practically those of chronic
valvular disease, and the general influence on the work of the heart may
be briefly stated as follows : The sclerosis induces insufficiency or ste-
nosis, which may exist separately or in combination. The narrowing re-
tards in a measure the normal outflow and the insufficiency permits the
blood current to take an abnormal course. In both instances the effect is
dilatation of a chamber. The result in the former case is an increase
in the difficulty which the chamber has in expelling its contents through
the narrow orifice ; in the other, the overfilling of a chamber by blood
flowing into it from an improper source, as, for instance, in mitral insuf-
ficiency, when the left auricle receives blood both from the pulmonary
veins and from the left ventricle.
The cardiac mechanism is fully prepared to meet ordinary grades of
dilatation which constantly occur during sudden exertion. A man, for
instance, at the end of a hundred-yard race has his right chambers
greatly dilated and his reserve cardiac power worked to its full capacity.
The slow progress of the sclerotic changes brings about a gradual, not an
abrupt, insufficiency, and the moderate dilatation which follows is at first
overcome by the exercise of the ordinary reserve strength of the heart
muscles. Gradually a new factor is introduced. The reserve power which
is capable of meeting sudden emergencies in such a remarkable manner is
unable to cope long with a permanent and perhaps increasing dilatation.
More work has to be done and, in accordance with definite physiological
laAVS, more power is given by increase of the muscles. The heart hyper-
trophies and the effect of the valve lesion becomes, as we say, compen-
sated. The equilibrium of the circulation is in this way maintained.
602 DISEASES OF THE CIRCULATORY SYSTEM.
II. CHRONIC VALVULAR DISEASE.
Aortic Incompetency.
Incompetency of the aortic valves arises either from inability of the
valve segments to close an abnormally large orifice or more commonly
from disease of the segments themselves. This best-defined and most
easily recognized of valvular lesions was first carefully studied by Corrigan,
whose name it sometimes bears.
Etiology and Morbid Anatomy. — It is more frequent in males
than in females, affecting chiefly able-bodied, vigorous men at the middle
period of life. The ratio which it bears to other valve diseases has been
variously given from thirty to fifty per cent.
Among the important factors in producing this condition are : (a)
Congenital malformation, particularly fusion of two segments — most
commonly those behind which the coronary arteries are given off. It is
probable that an aortic orifice may be competent with this bicuspid state
of the valves, but a great danger is the liability of these malformed segments
to sclerotic endocarditis. Of seventeen cases which I have reported all
presented sclerotic changes, and the majority of them had, during life, the
clinical features of chronic heart-disease.
(b) Acute endocarditis. This does not produce aortic incompetency
unless the process passes on to ulceration and destruction, under which
circumstances it is often found, and may cause a rapidly fatal issue. Sim-
ple endocarditis associated with the specific fevers is not nearly so com-
mon on the aortic as on the mitral segments ; so also with rheumatism,
which plays a less important role here than in mitral valve disease.
{c) By far the most frequent cause of insufficiency is the slow, pro-
gressive sclerosis of the segment, resulting in a curling of the edge,
which lessens the working surface of the valve. This may, of course, fol-
low acute endocarditis, but it is so often met with in strong, able-bodied
men among the working classes, without any history of rheumatism or
special febrile diseases with which endocarditis is commonly associated,
that other conditions mast be sought for to explain its frequency. Of
these, unquestionably strain is the most important — not a sudden, forcible
strain, but a persistent increase of the normal tension to which the
segments are subject during the diastole of the ventricle. Of circum-
stances increasing this tension, heavy and excessive use of the muscles is
perhaps the most important. So often is this form of heart-disease found
in persons devoted to athletics that it is sometimes called the " athlete's
heart." Alcohol is a second important factor, and is stated to raise con-
siderably the tension in the aortic system. A combination of these two
causes is extremely common. A third element in inducing chronic scle-
rotic changes in these valves is syphilis. Cases are rarely seen in which
other factors must not be taken into account, but the association is too
CURONIC VALVULAR DISEASE. 603
frequent to be accidental. That syphilis is capable of inducing arterial
sclerosis is, I think, acknowledged, although the way in which it is done is
not yet clear. It is interesting to note with what frequency this form of
valve disease occurs in soldiers. I was struck with this fact in the Phila-
delphia Hospital, to which so many veterans of the civil war are admitted.
I was in the habit of enforcing upon my students the etiological lesson by
a mythological reference to Bacchus and Vulcan, at whose shrines a ma-
jority of the cases of aortic insufficiency have worshipped, and not a few
at that of Venus.
The condition of the valves is such as has already been described in
chronic endocarditis. It may be noted, however, how slight a grade of
curling may produce serious incompetency. Associated with the valve
disease is, in a majority of the cases, a more or less advanced arterio-scle-
rosis of the arch of the aorta, one serious effect of which may be a narrow-
ing of the orifices of the coronary arteries. The sclerotic changes are
often combined with atheroma, either in the fatty or calcareous stage.
This may exist at the attached margin of the valves without inducing in-
sufficiency. In other instances insufficiency may result from a calcified
spike projecting from the aortic attachment into the body of the valve,
and so preventing its proper closure. Some writers (Peter) have laid
great stress upon the extension of the endarteritis to the valve, and would
separate the instances of this kind from those of simple valvular endocar-
ditis. I must say that I have not been able to recognize clinical differ-
ences between these two conditions, though anatomically we may separate
the cases into two groups — those wdth and those without arterio-sclerosis.
(d) And, lastly, insufficiency may be induced by rupture of a segment
— a very rare event in healthy valves, but not uncommon in disease,
either from excessive strain during heavy lifting or from the ordinary
endarterial strain in a valve eroded and weakened by ulcerative endo-
carditis.
Relative insufficiency of the sigmoid valves, due to dilatation of the
aortic ring, is a rare condition. It is said to occur in extensive arterial
sclerosis of the ascending portion of the arch with great dilatation just
above the valves. I have myself never met with a pure instance of the
kind, for in such cases I have always found the valve segments involved
with the arterial coats. In aneurism just above the aortic ring, relative
insufficiency of the valve may be present.
It would appear from the careful measurements of Beneke that the
aortic orifice, which at birth is 20 mm., increases gradually with the
growth of the heart until at one and twenty it is about 60 mm. ' At this
it remains until the age of forty, beyond which date there is a gradual
increase in the size up to the age of eighty, when it may reach from 68
to 70 mm. There is thus at the very period of life in which sclerosis of
the valve is most common a physiological tendency toward the production
of a state of relative insufficiency.
39
604 DISEASES OF THE CIRCULATORY SYSTEM.
The insufficiency may be combined with various grades of narrowing,
but the majority of the cases of aortic insufficiency present no signs of
stenosis. On the other hand, cases of aortic stenosis almost without
exception are associated with some grade, however slight, of regurgitation.
The direct effect of aortic insufficiency is the regurgitation of blood
from the artery into the ventricle, causing an overdistention of the cavity
and a reduction of the blood column ; that is, a relative anaemia in the
arterial tree. As an immediate effect of the double blood-flow into the
left ventricle dilatation of the chamber occurs, and finally hypertrophy.
In this way the valve defect is compensated and as with each ventricular
systole a larger amount of blood is propelled into the arterial system, the
regurgitation of a certain amount during diastole does not, for a time at
least, seriously impair the nutrition of the peripheral parts. In this valve
lesion dilatation and hypertrophy reach their most extreme limit. The
heaviest hearts on record are described in connection with this affection.
The so-called bovine heart, cor bovmum, may weigh 35 or 40 ounces, or
even, as in a case of Dulles's, 48 ounces. The dilatation is usually ex-
treme, and is in marked contrast 'to the condition of the chamber in cases
of pure aortic stenosis. The papillary muscles may be greatly flattened.
The mitral valves are usually not seriously affected, though the edges
may present slight sclerosis, and there is often relative incompetency,
owing to distention of the mitral ring. Dilatation and h}^ertrophy of
the left auricle are common, and secondary enlargement of the right heart
occurs in all cases of long standing. The myocardium usually presents
changes, fibroid or fatty ; more commonly the former in association with
disease of the coronary arteries. The arch of the aorta may present
extensive arterio-sclerosis and dilatation. In rare instances, usually the
rheumatic cases, the intima is perfectly smooth, and the arch with its
main branches not dilated. This condition may be found post mortem
even when during life there have been the most characteristic signs of
enlargement of the arch and of dilatation of the innominate and right
carotid. I have even known the condition of aneurism to be diagnosed
when post mortem no trace of dilatation or sclerosis was found, only an
extreme grade of insufficiency with enormous dilatation and hypertrophy.
The coronary arteries are usually involved in the sclerosis, and their
orifices may be much narrowed. Although these vessels have been shown
by Martin and Sedgwick to be filled during the ventricular systole, the
circulation in them must be embarrassed in aortic incompetency. They
must miss the effect of the blood-pressure in the sinuses of Valsalva dur-
ing the elastic recoil of tlie arteries, which surely aids in keeping the
coronary vessels full. The arteries of the body usually present more or
less sclerosis consequent upon the strain which they undergo during the
forcible ventricular systole.
Symptoms. — The condition is often discovered accidentally in per-
sons who have not presented any features of cardiac disease.
CHRONIC VALVULAR DISEASE. 005
Physical Signs. — Inspection shows a wide and forcible area of cardiac
impulse with tlie apex beat in the sixth or seventh interspace, and per-
haps as far out as the anterior axillary line. In young subjects the
praecordia may bulge. On palpation a thrill, diastolic in time, is occa-
sionally felt, but is not common. The impulse is usually strong and
heaving, unless in conditions of extreme dilatation, when it is wavy and
indefinite. Percussion shows a greater increase in the area of heart dul-
ness than is found in any other valvular lesion. It extends chiefly down-
ward and to the left.
On auscultation there is heard a murmur during diastole in the second
right interspace, which is propagated with intensity toward the ensiform
cartilage or down the left margin of the sternum toward the apex. In
the majority of cases it is a soft, long-drawn hruit^ and is of all cardiac
murmurs the most reliable. It occurs during the time of, and is produced
by, the reflux of blood from the aorta into the ventricle. In a large joro-
portion of the cases there is also a systolic murmur heard at the aortic
region, usually shorter, often rougher in quality, and which may be propa-
gated upward into the neck. A common mistake is to regard this as
indicating stenosis, whereas in the great majority of instances of aortic
insufficiency there is no material narrowing, and the murmur is produced
by roughening of the segments or of the intima of the arch. The second
sound is usually obliterated, though in some instances both the murmur
and the valvular sound may be distinctly heard. At the apex murmurs
are also heard, either transmitted from the aortic oriflce or produced at
the mitral. In the majority of cases with aortic incompetency of high
grade, the mitral orifice is dilated, and there is relative insufficiency of the
valves. It can frequently be determined that the systolic murmur at the
apex differs in quality from that at the base. A second murmur at the
apex, probably produced at the mitral orifice, is not infrequent. Atten-
tion was called to this by the late Austin Flint, and the murmur usually
goes by his name. It has a distinctly rumbling quality, is limited in area,
and is sometimes, though not always, distinctly presystolic in time. The
explanation of its occurrence, as given by Flint, is that in the extreme
dilatation of the ventricle the mitral segments cannot during diastole be
forced back against the wall, and, therefore, remaining in the blood cur-
rent, they produce a sort of relative narrowing, and in consequence a
vibratory murmur not unlike in quality the presystolic murmur of mitral
stenosis. My experience as to the frequency of this murmur coincides
with that of Lee.*
The examination of the arteries in aortic insufficiency is of great value.
Visible pulsation is more commonly seen in the peripheral vessels in this
than in any other condition. The carotids may be seen to throb forcibly,
the temporals to dilate, and the brachials and radials to expand with each
* American Journal of the Medical Sciences, 1890.
606 DISEASES OF THE CIRCULATORY SYSTEM.
lieart-beat. With the ophthalmoscope the retinal arteries are seen to
jiulsate. Xot only is the pulsation evident, but the characteristic jerking
quality is apparent. In the throat the throbbing carotids may lead to the
diagnosis of aneurism. In many cases the pulsation can be seen in the
suprasternal notch, and prominent, forcibly-throbbing vessels beneath the
right sterno-mastoid muscle. The abdominal aorta may lift the epigastrium
with each systole. To be mentioned with this is the capillary pulse, met
very often in aortic insufficiency, and best seen in the finger-nails or by
drawing a line upon the forehead, when the margin of hyperaemia on either
side alternately blushes and pales. In extreme grades the face or the
hand may blush visibly at each systole. It is met with also in profound
anaemia, occasionally in neurasthenia, and in health in conditions of great
relaxation of the perij^heral arteries. Pulsation may also be present in
the peripheral veins. On palpation the characteristic water-hammer or
Corrigan pulse is felt. On the majority of instances the pulse wave strikes
the finger forcibly with a quick jerking impulse, and immediately recedes
or collapses. The characters of this are sometimes best appreciated by
grasping the arm above the wrist and holding it up. On auscultation
a double murmur may be heard in the carotids and subclavians when it
is present at the aortic orifice. Occasionally in the carotid the second
sound is distinctly audible when absent at the aortic cartilage. In the
femoral artery a double murmur also 'may be heard sometimes, as pointed
out by Duroziez.
Aortic insufficiency may for years be fully compensated. Persons do
not necessarily suffer any inconvenience, and the condition is often found
accidentally. So long as the hypertrophy just equalizes the valvular
defect there may be no symptoms and the individual may even take
moderately heavy exercise without experiencing sensations of distress
about the heart. The cases which last the longest are those in which the
sclerosis follows endocarditis and is not a part of a general arterio-sclero-
sis. Coexistent lesions of the mitral valves tend early to disturb the
compensation. It has scarcely been sufficiently recognized by the profes-
sion at large that pure aortic insufficiency is consistent with years of aver-
age health and with a tolerably active life. I know several physicians with
aortic insufficiency who have been able to carry on for years large and
somewhat onerous practices. One of them since the establishment of insuf-
ficiency has passed successfully tlirough two attacks of acute rheumatism.
In large hospital practice, scarcely a month passes without the discovery
of a case of aortic insufficiency in connection with some other affection.
"With the onset of myocardial changes, with increasing degeneration of
the arteries, particularly with a progressive sclerosis of the arch and in-
volvement of the orifices of the coronary arteries, the compensation be-
comes disturbed. In advanced cases the changes about the aortic ring
may be associated with alterations in the cardiac nerves and ganglia, and
so introduce an important factor.
CHRONIC VALVULAR DISEASE. 607
Headache, dizziness, flaslies of light, and a feeling of faintness on ris-
ing quickly are among the earliest symptoms. Palpitation and cardiac
distress on slight exertion are common. Long before any signs of failing
compensation pain may become a marked and troublesome feature. It is
extremely variable in its manifestations. It may be of a dull, aching char-
acter confined to the praecordia. More frequently, however, it is sharp
and radiating, and is transmitted up the neck and down the arms, par-
ticularly the left. Attacks of true angina pectoris are more frequent in
this than in any other valvular disease. Anaemia is also common, much
more so than in aortic stenosis or in mitral affections.
More serious symptoms, as compensation fails, are shortness of breath
and oedema of the feet. The attacks of dyspnoea are liable to come on at
night and the patient has to sleep with the head high or even in a chair.
Of respiratory symptoms cough may develop, due to the congestion of
the lungs or oedema. Haemoptysis is less frequent than in mitral disease.
I have reported a case in which it was profuse and believed to be due to
tuberculosis of the lungs, inasmuch as the patient was admitted in a state
of emaciation and profound exhaustion. General dropsy is not common,
but oedema of the feet may occur early and is sometimes due to the ana3-
mia, at others to the venous stasis, at times to both. Unless there is co-
existing disease of the mitral valve, it is rare in pure aortic incompe-
tency for the patient to die with general anasarca. Sudden death is fre-
quent ; more so in this than in other valvular diseases. As compensation
fails the patient takes to bed and slight irregular fever, associated usually
with a recurring endocarditis, is not uncommon toward the close. Em-
bolic symptoms are not infrequent — pain in the splenic region with en-
largement of the organ, haematuria, and in some cases paralysis. Dis-
tressing dreams and disturbed sleep are more common in this than in other
forms of valvular disease.
Here may appropriately be mentioned the connection between mental
symptoms and cardiac disease, as they are oftenest seen with this lesion.
An admirable account of the relations between insanity and disease of
the heart is to be found in Mickle's Gulstonian lectures for 1888. In
general medical practice we seldom find marked mental symptoms, except
toward the close of the disease, when there may be delirium, hallucinations,
and morbid impulses. It is to be remembered that in many heart cases
this terminal delirium is uraemic. The irritability and peevishness some-
times found in persons the subject of organic heart-disease cannot, I think,
be associated with it in any special manner. We do meet insanity, break-
ing out in patients with aortic and mitral disease, in the stage of compen-
sation, which appears to be related definitely to the cardiac lesion. It is
important to b(!ar this in mind, for cases occasionally display suicidal
tendencies. I have twice had patients throw themselves from the window
of the ward.
608 DISEASES OP THE CIRCULATORY SYSTEM.
Aortic Stenosis.
Xarrowing or stricture of the aortic orifice is not nearly so common as
insufficiency. The two conditions, as already stated, may occur together,
liowevcr, and probably in almost every case of stenosis there is some leakage.
Etiology and Morbid Anatomy. — In the milder grades there is
adhesion between the segments, which are so stiffened that during systole
they cannot be pressed back against the aortic wall. The process of co-
hesion between the segments may go on Avithout great thickening, and
produce a condition in which the orifice is guarded by a comparatively
thin membrane, on the aortic face of which may be seen the primitive
raphes separating the sinuses of Valsalva. In some instances this mem-
brane is so thin and presents so few traces of atheromatous or sclerotic
changes that the condition looks as if it had originated during foetal life.
More commonly the valve segments are thickened and rigid, and have a
cartilaginous hardness. In advanced cases they may be represented by
stiff, calcified masses obstructing the orifice, through which a circular or
slit-like passage can be seen. The older the patient the more likely it is
that the valves will be rigid and calcified.
We may speak of a relative stenosis of the aortic orifice when with
normal valves and ring the aorta immediately beyond is greatly dilated.
A stenosis due to involvement of the aortic ring in sclerotic and calcareous
changes without lesion of the valves is referred to by some authors. I have
never met with an instance of this kind. A subvalvular stenosis, the result
of endocarditis in the mitro-sigmoidean sinus, usually occurs as the re-
sult of a foetal endocarditis. In comparison with aortic insufficiency, ste-
nosis is a rare disease. It is usually met with at a more advanced period
of life than insufficiency, and the most typical cases of it are found asso-
ciated w^ith extensive calcareous changes in the arterial system in old men.
When gradually produced and when there is not much insufficiency
the dilatation of the left ventricle may be slight, though I think that
in all cases it does occur. The walls of the ventricle become hypertro-
phied, and we see in this condition the most typical instances of what is
called concentric hypertrophy, in which, without much, if any, enlarge-
ment of the cavity, the walls are greatly thickened, in contradistinction
to the so-called eccentric h}^ertrophy, in which the chamber is greatly
dilated as well as hypertrophied. There may be no changes in the other
cardiac cavities if compensation is well maintained ; but with its failure
come dilatation, impeded auricular discharge, pulmonary congestion, and
increased work for the right heart. The arterial changes are, as a rule,
not so marked as in aortic insufficiency, for the walls have not to with-
stand tlie impulse of a greatly increased blood-wave with each systole. On
the contrary, the amount of blood propelled through the narrow orifice
may be smaller than normal, though when compensation is fully estab-
lished the pulse-wave may be of medium volume.
CHRONIC VALVULAR DISEASE. G09
Symptoms. Physical Signs. — Insjjectloii may fail to reveal any
area of cardiac impulse. Particularly is this the case in old men with
rigid chest walls and large emphysematous lungs. Under these circum-
stances there may be a high grade of. hypertrophy without any visible im-
pulse. Even when the apex beat is visible it may be, as Traube pointed
out, feeble and indefinite. In many cases the apex is seen displaced down-
ward and outward, and the impulse looks strong and forcible.
Palpation reveals in many cases a thrill at the base of the heart of
maximum force in the aortic region. With no other condition do we
meet with thrills of greater intensity. The apex beat may not be palpable
under the conditions above mentioned, or there may be a slow, heaving,
forcible impulse.
Percussion never gives the same wide area of dulness as in aortic in-
sufficiency. The extent of it depends largely on the state of the lungs,
whether emphysematous or not.
Auscultation. — A systolic murmur of maximum intensity at the aortic
cartilage, and propagated into the great vessels, is 23resent in aortic ste-
nosis, but is by no means pathognomonic. One of the last lessons learned
by the student of physical diagnosis is to recognize the fact that this sys-
tolic murmur is only in comparatively rare cases produced by decided
narrowing of the aortic orifice. Eoughening of the valves, or the intima
of the aorta, and haemic states are much more frequent causes. In aortic
stenosis the murmur often has a much harsher quality, is louder, and is
more frequently musical than in the conditions just mentioned. "When
compensation fails and the ventricle is dilated and feeble the murmur
may be soft and distant. The second sound is rarely heard at the aortic
cartilage, owing to the thickening and stiffness of the valve. A diastolic
murmur is not uncommon, but in many cases it cannot be heard. The
pulse in pure aortic stenosis is small, usually of good tension, regular,
and perhaps slower than normal.
The condition may be latent for an indefinite period, as long as the
h3rpertrophy is maintained. Early symptoms are those due to defective
blood-supply to the brain, dizziness, and fainting. Palpitation, pain
about the heart, and anginal symptoms are not so marked as in insuffi-
ciency. With degeneration of the heart-muscle and dilatation relative
insufficiency of the mitral valve is established, and the patient may present
all the features of engorgement in the lesser and systemic circulations,
with dyspnoea, cough, rusty expectoration, and the signs of anasarca in the
lower part of the body. Many of the cases in old people, without present-
ing any dropsy, have symptoms pointing rather to general arterial disease.
Cheyne-Stokes breathing is not uncommon with or without signs of
uraemia.
Diagnosis. — With an intensely rough or musical murmur of maximum
intensity at the aortic region and signs of hypertrophy of the left ventricle,
a thrill and a hard, slow pulse of moderate volume and fairly good tension,
610 DISEASES OF THE CIRCULATORY SYSTEM.
a diagnosis of aortic stenosis can be made with some degree of probability,
particularly if the subject is an old man. Mistakes are common, how-
ever, and a roughened or calcified valve segment, or, in some instances,
a very roughened and prominent calcified plate in the aorta, and
liypertropliy associated with renal disease, may produce similar symp-
toms.
Let me repeat that a murmur of maximum intensity at the aortic
cartilage is of no importance in itself as a diagnostic sign of stenosis.
Roughening of the valve, sclerosis of the intima of the arch, and anaemia
are conditions more frequently associated with a systolic murmur in this
region. Seldom is there difficulty in distinguishing the murmur due to
anaemia, since it is rarely so intense and is not associated with thrill or
with marked hypertrophy of the left ventricle. In aortic insufficiency a
systolic murmur is usually present, but has neither the intensity nor the
musical quality, nor is it accompanied with a thrill. With roughening
and dilatation of the ascending aorta the murmur may be very harsh or
musical ; but the existence of a second sound, accentuated and ringing in
quality, is usually sufficient to differentiate this condition.
Mitral Incompetency.
Etiology. — Insufficiency of the mitral valve results from : (a)
Changes in the segments whereby they are contracted and shortened,
usually combined with changes in the chordae tendineae, or with more or
less narrowing of the orifice, (b) As a result of changes in the muscular
Avails of the ventricle, either dilatation, so that the valve segments fail to
close an enlarged orifice, or changes in the muscular substance, so that
the segments are imperfectly coapted during the systole — muscular in-
competency. The common lesions producing insufficiency result from
endocarditis, which causes a gradual thickening at the edges of the valves,
contraction of the chordae tendineae, and union of the edges of the seg-
ments, so that in a majority of the instances there is not only insuffi-
ciency, but some grade of narrowing as well. Except in children, we
rarely see the mitral leaflets curled and puckered without narrowing of
the orifice. Calcareous plates at the base of the valve may prevent per-
fect closure of one of the segments. In long-standing cases the entire
mitral structures are converted into a firm calcareous ring. From this
valvular insufficiency the other condition of muscular incompetency must
be carefully distinguished. It is met with in all conditions of extreme
dilatation of the left ventricle, and also in weakening of the muscles in
prolonged fevers and in ana3mia.
Morbid Anatomy. — The effects of incompetency of the mitral
segment upon the heart and circulation are as follows : (a) The imperfect
closure allows a certain amount of blood to regurgitate from the ventricle-
into the auricle, so that at the end of auricular diastole this chamber con-
CnRONIC VALVULAR DISEASE. 611
tains not only the blood which it has received from the lungs, but also
that which has regurgitated from the left ventricle. This necessitates
dilatation, and, as increased work is thrown upon it in expelling the aug-
mented contents, hypertrophy as welL
{b) AVith each systole of the left auricle a larger volume of blood is
forced into the left ventricle, which also dilates and subsequently becomes
hypertrophied.
(c) During the diastole of the left auricle, as blood is regurgitated
into it from the left ventricle, the pulmonary veins are less readily emptied.
In consequence the right ventricle expels its contents less freely, and in
turn becomes dilated and hypertrophied.
(d) Finally, the right auricle also is involved, its chamber is enlarged,
and its walls are increased in thickness.
{e) The effect upon the pulmonary vessels is to produce dilatation
both of the arteries and veins — often in long-standing cases atheromatous
changes; the capillaries are distended, and ultimately the condition of
brown induration is produced. Perfect compensation may be effected,
chiefly through the hypertrophy of both ventricles, and the effect upon
the peripheral circulation may not be manifested for years, as a normal
volume of blood is discharged from the left heart at each systole. The
time comes, however, when, owing either to increase in the grade of the
incompetency or to failure of the compensation, the left ventricle is
unable to send out its normal volume into the aorta. Then there is over-
filling of the left auricle, engorgement in the lesser circulation, embarrassed
action of the right heart, and congestion in the systemic veins. For years
this somewhat congested condition may be limited to the lesser circulation,
but finally the right auricle becomes dilated, the tricuspid valves incom-
petent, and the systemic veins are engorged. This gradually leads to the
condition of cyanotic induration in the viscera and, when extreme, to
dropsical effusion.
Muscular incompetency, due to impaired nutrition of the mitral and
papillary muscles, is rarely followed by such perfect compensation. There
may be in acute destruction of the aortic segments an acute dilatation of
the left ventricle with relative incompetency of the mitral segments, great
dilatation of the left auricle, and intense engorgement of the lungs, under
which circumstances profuse haemorrhage may result. In these cases
there is little chance for the establishment of compensation. In cases
of hypertrophy and dilatation of the heart, without valvular lesions, but
associated with heavy work and alcohol, the insufficiency of the mitral
valve may be extreme and lead to great pulmonary congestion, engorge-
ment of the systemic veins, and a condition of cardiac dropsy, which
cannot be distinguished by any feature from that of mitral incompetency
due to lesion of the valve itself. In chronic J^right's disease the hyper-
trophy of the left ventricle may gradually fail, leading, in the later stages,
to relative insufficiency of the mitral valve, and the production of a con-
612 DISEASES OF THE CIRCULATORY SYSTEM.
dition of pulmonary and systemic congestion, similar to that induced by
the most extreme grade of lesion of the valve itself.
Symptoins. — During the development of the lesion, unless the in-
competency comes on acutely in consequence of rupture of the valve
segment or of ulceration, the compensatory changes go hand in hand
with the defect, and there are no subjective symptoms. So, also, in the
stage of perfect compensation, there may be the most extreme grade of
mitral insufficiency with enormous hypertrophy of the heart, yet the
patient may not be aware of the existence of heart trouble, and may
suffer no inconvenience except perhaps a little shortness of breath on
exertion or on going up-stairs. It is only when from any cause the com-
pensation has not been perfectly effected, or having been so is broken
abruptly or gradually, that the patients begin to be troubled. The symp-
toms may be divided into two groups :
(a) The minor manifestations while compensation is still good. Pa-
tients with extreme incompetency often have a congested appearance of
the face, the lips and ears have a bluish tint, and the venules on the
cheeks may be enlarged, which in many cases is very suggestive. In
long-standing cases, particularly in children, the fingers may be clubbed,
and there is shortness of breath on exertion. This is one of the most
constant features in mitral insufficiency, and may exist for years, even
when the compensation is perfect. Owing to the somewhat congested
condition of the lungs these patients have a tendency to attacks of
bronchitis or haemoptysis. There may also be palpitation of the
heart. As a rule, however, in well-balanced lesions in adults, this
period of full compensation or latent stage is not associated with symp-
toms which call the attention of the patient to an affection of the
heart.
(b) Sooner or later comes a period of disturbed or broken compensa-
tion, in which the most intense symptoms are those of venous engorgement.
There are palpitation, weak, irregular action of the heart, and signs of
dilatation. Dyspnoea is a marked feature, and there may be cough.
There is usually a slight cyanosis, and even a jaundiced tint to the skin.
The most marked symptoms, however, are those of venous stasis. The
overfilling of the pulmonary vessels accounts in part for the dyspnoea.
There is cough, often with bloody or watery expectoration, and the
alveolar epithelium containing brown pigment-grains is abundant. Drop-
sical effusion usually sets in, beginning in the feet and extending to the
body and the serous sacs. The liver is enlarged, and there are signs of
portal congestion, gastric irritation, and catarrh of the stomach and in-
testines. Tlie urine is usually scanty and albuminous, and contains tube
casts and sometimes blood-corpuscles. With judicious treatment the
compensation may be restored and all the serious symptoms may pass
away. Patients may have recurring attacks of this kind, but ultimately
the condition is beyond repair and the patient either dies of a general
CnRONIC VALVULAR DISEASE. ^13
dropsy or there is progressive dilatation of the heart, and death from
asystole. Sudden death in these cases is rare.
Physical Signs. — Inspection, — In children the praecordia may bulge
and there may be a large area of visible pulsation. The apex beat is to
the left of the nipple, in some cases in the sixth interspace, in the anterior
axillary line. There may be a wavy im^iulse in the cervical veins which
are often full, particularly when the patient is recumbent.
PaJimtion. — A thrill is rare ; when present it is felt at the apex,
often in a limited area. The force of the impulse may depend largely
upon the stage in which the case is examined. In full compensation it is
forcible and heaving ; when the compensation is disturbed, usually wavy
and feeble.
Percussion. — The dulness is increased, particularly in a lateral direc-
tion. There is no disease of the valves which produces, in long-standing
cases, a more extensive transverse area of heart dulness. It does not ex-
tend so much upward along the left margin of the sternum as beyond the
right margin and to the left of the nipple line.
Auscultation. — At the apex there is a systolic murmur which wholly
or partly obliterates the first sound. It is loudest here, and has a blowing,
sometimes musical in character, joarticularly toward the latter part. The
murmur is transmitted to the axilla and may be heard at the back, in
some instances over the entire chest. There are cases in which, as pointed
out by Xaunyn, the murmur is heard best along the left border of the
sternum. Usually in diastole at the apex the loudly transmitted second
sound may be heard. Occasionally there is also a soft, sometimes a
rough or rumbling presystolic murmur. As a rule, in cases of extreme
mitral insufficiency from valvular lesion with great Iwpertrophy of both
ventricles, there is heard only a loud blowing murmur during systole.
A murmur of mitral insufficiency may vary a great deal according to the
position of the patient. It may be present in the recumbent and ab-
sent in the erect posture. In cases of dilatation, particularly when dropsy
is present, there may be heard at the ensiform cartilage and in the lower
sternal region a soft systolic murmur due to tricuspid regurgitation. An
important sign on auscultation is the accentuated pulmonary second sound.
This is heard to the left of the sternum in the second interspace, or over
the third left costal cartilage.
The pulse in mitral insufficiency, during the period of full compensa-
tion, may be full and regular, often of low tension. Usually with the first
onset of the symptoms the pulse becomes irregular, a feature which then
dominates the case throughout. There may be no two beats of equal
force or volume. Often after tlie disappearance of the symptoms of fail-
ure of compensation the irregularity of the pulse persists.
The three important physical signs then of mitral regurgitation are:
{a) systolif; murmur of maximum intensity at the apex, which is propa-
gated to the axilla and heard at the angle of the scapula; [b) accentuation
Qli DISEASES OF THE CIRCULATORY SYSTEM.
of the pulmonary second sound ; (c) evidence of enlargement of the heart,
particularly the increase in the transverse diameter, due to hypertrophy
of both right and left ventricles.
Diagnosis. — There is rarely any difficulty in the diagnosis of mitral
insufficiency. The physical signs just referred to are quite characteristic
and distinctive. Two points are to be borne in mind. First, a murmur,
systolic in character, and of maximum intensity at the apex, and propa-
gated even to the axilla, does not necessarily indicate incompetency of the
mitral valve. There is heard in this region a large group of what are
termed accidental murmurs, the precise nature of which is still doubtful.
They are probably formed, however, in the ventricle, and are not associated
with hypertrophy, or accentuation of pulmonary second sound.
Second, it is not always possible to say whether the insufficiency is
due to lesion of the valve segment or to dilatation of the mitral ring and
relative incompetency. Here neither the character of the murmur, the
propagation, the accentuation of the pulmonary second sound, nor the
hypertrophy assists in the differentiation. The history is sometimes of
greater value in this matter than the physical examination. The cases
most likely to lead to error are those of the so-called idiopathic dilatation
and hypertrophy of the heart (in which the systolic murmur may be of
the greatest intensity), and the instances of arterio-sclerosis with dilated
heart.
Mitral Stenosis.
Etiology. — Narrowing of the mitral orifice is usually the result of
valvular endocarditis occurring in the earlier years of life ; very rarely it
is congenital. It is very much more common in women than in men — in
63 of 80 cases noted by Duckworth. This is not easy to explain, but there
are at least two factors to be considered. Eheumatism prevails more in
girls than in boys and, as is well known, endocarditis of the mitral valve
is more common in rheumatism. Chorea, also, as suggested by Barlow,
has an important influence, occurring more frequently in girls and often
associated with endocarditis. Of 110 cases of chorea which I examined at
a period more than two years subsequent to the attack, 54 cases liad signs
of organic heart-disease, among which were 17 instances with the physical
signs of mitral stenosis. Anaemia and chlorosis, which are prevalent in
girls, have been regarded as possible factors. In a number of cases, how-
ever, no recognizable etiological factor can be discovered. This has been
regarded by some writers as favoring the view that many of the cases are
of congenital origin ; but it is not improbable that with any of the febrile
affections of childhood endocarditis may be associated. Whooping-cough,
too, with its terrible strain on the heart-valves, may be accountable for
certain cases. Congenital affections of the mitral valve are notoriously
rare. While met with at all ages, stenosis is certainly more frequent in
young persons.
CHRONIC V^ALVULAR DISEASE. G15
Morbid Anatomy. — In a majority of instances witli tlie stenosis
there is some incompetency. The narrowing results from thickening and
contraction of the tissues of the ring, of the valve segments, and of the
chordas tendineae. The condition varies a good deal according to the
amount of atheromatous change. In many cases the curtains are so
welded together and the whole valvular region so thickened that the
orifice is reduced to a mere chink — Corrigan's button-hole contraction.
In other cases the curtains are not much thickened, but narrowing has
resulted from gradual adhesion at the edges, and thickening of the chordae
tendineae, so that from the auricle it looks cone-like — the so-called funnel-
shaped variety of stenosis. The instances in which the valve segments
are very slightly deformed but in which the orifice is considerably nar-
rowed, are regarded by some as possibly of congenital origin. Occa-
sionally the curtains are in great part free from disease, but the nar-
rowing results from large calcareous masses, which project into them
from the ring. The involvement of the chordae tendineae is usually ex-
treme, and the papillary muscles may be inserted directly upon the
valve. In moderate grades of constriction the orifice will admit the tip
of the index-finger ; in more extreme forms, the tip of the little finger ;
and occasionally one meets with a specimen in which the orifice seems
almost obliterated, as in a case which came under my notice, which only
admitted a medium-sized Bowman's probe.
The heart in mitral stenosis is not greatly enlarged, rarely weighing
more than 14 or 15 ounces. Occasionally, in an elderly person, it may
seem slightly if at all enlarged, and again there are instances in which
the weight may reach as much as 20 ounces. The left ventricle is usually
small, and may look very small in comparison with the right ventricle,
which forms the greater portion of the apex. In cases in which with the
narrowing there is very considerable incompetency the left ventricle may
be moderately dilated and hypertrophied.
These changes gradually induced are associated with secondary altera-
tions of great importance in the heart. The left auricle discharges its
blood with greater difficulty and in consequence dilates, and its walls
reach three or four times their normal thickness. Although the auricle is
by structure unfitted to compensate an extreme lesion, the probability is
that for some time during the gradual production of stenosis, the increas-
ing muscular power of the walls is sufficient to counterbalance the defect.
Eventually the tension is increased in the pulmonary circulation, owing
to impeded outflow from the veins. To overcome this the right tentricle
undergoes dilatation and hypertrophy, and upon this chamber falls the
work of equalizing the circulation. Relative incompetency of tlie tricuspid
and congestion of systemic veins at last supervene.
It is not uncommon at the examination to find white thrombi in the
appendix of the left auricle. Occasionally a large part of the auricle is
occupied by an ante-mortem thrombus. Still more rarely the remarkable
616 DISEASES OF THE CIRCULATORY SYSTEM.
ball thrombus is found, in which a globular concretion, varying in size
from a walnut to a small egg, lies free in the auricle, two examples of
which have come under my observation.
Symptoms. — Physical Signs. — Inspectmi. — In children the lower
sternum and the fifth and sixth left costal cartilages are often prominent,
owing to hypertrophy of the right ventricle. The apex beat may be ill-
defined. Usually, it is not dislocated far beyond the nipple line, and the
chief impulse is over the lower sternum and adjacent costal cartilages.
Often in thin-chested persons there is pulsation in the third and fourth
left interspaces close to the sternum. AVhen compensation fails, the prae-
cordial impulse is much feebler, and in the veins of the neck there may
be marked systolic regurgitation.
Palpatio7i reveals in a majority of the cases a characteristic, well-
defined fremitus or thrill, which is best felt, as a rule, in the fourth or
fifth interspace within the nipple line. It is of a rough, grating quality,
often peculiarly limited in area, most marked during expiration, and can
be felt to terminate in a sharp, sudden shock, synchronous with the im-
pulse. This most characteristic of physical signs is pathognomonic of
narrowing of the mitral orifice, and is perhaps the only instance in which
the diagnosis of a valvular lesion can be made by palpation alone. The
cardiac impulse is felt most forcibly in the lower sternum and in the
fourth and fifth left interspaces. The impulse is felt very high in the third
and fourth interspaces, or in rare cases even in the second, and it has
been thought that in the latter interspace the impulse is due to pulsa-
tion of the auricle. It is always the impulse of the right ventricle ; even
in the most extreme grades of mitral stenosis, there is never such tilting
forward of the auricle or Its appendix as would enable it to produce an
impression on the chest wall.
Percussion gives an increase in the cardiac dulness to the right of the
sternum and along the left margin ; not usually a great increase beyond
the nipple line, except in extreme cases, when the transverse dulness may
reach from 5 cm. beyond the right margin of the sternum to 10 cm.
beyond the nipple line.
Auscultation. — In the mitral area, usually to the inner side of the
apex beat and often in a very limited region, is heard a rough, vibratory
or purring murmur, which terminates abruptly in the first sound. By
combining palpation and auscultation the purring murmur is found to be
synchronous with the thrill and the loud shock with the first sound. This
is the presystolic murmur, about the time and mode of production of which
so much discussion has occurred. I hold with those who regard it as oc-
curring during the auricular systole. In whatever way produced, it re-
mains one of the most distinctive and characteristic of murmurs and its
presence is positively indicative of narrowing of the mitral orifice. The
sole exception to this statement is the Flint murmur already referred to
in aortic incompetency. Once, in a case of enormous enlargement of the
CHRONIC VALVULAR DLSEASE. 617
spleen, with dropsy, in which the heart was greatly pushed up, I heard a
presystolic murmur of rough quality, and the mitral valves were found
post mortem to be normal. The presystolic murmur may occupy the
entire period of the diastole ; but more commonly it is only the latter half,
corresponding to the auricular systole. The difference may sometimes be
noted between the first and second portions of the murmur, when it occu-
pies the entire time. Often there is a peculiar rumbling or echoing qual-
ity, which in some instances is very limited and may be heard only over a
single bell-space of the stethoscope. A systolic murmur may be heard
at the apex or along the left sternal border, often of extreme softness and
audible only when the breath is held. Sometimes the systolic murmur is
loud and distinct and is transmitted to the axilla. The second sound in
the second left interspace is loudly accentuated, sometimes reduplicated.
It may be transmitted far to the left and be heard with great clearness
beyond the apex. In uncomplicated cases of mitral stenosis there are
usually no murmurs audible at the aortic region, at which spot the second
sound is less intense than at the pulmonary area. In the lower sternum
and to the right a tricuspid murmur is sometimes heard in advanced cases.
Other points to be noted are the following : The unusually sharp, clear
first sound which follows the presystolic murmur, the cause of which is
by no means easy to explain. It can scarcely be a valvular sound pro-
duced chiefly at the mitral orifice, since it may be heard with great inten-
sity in cases in which the valves are rigid and calcified. More probably it
is a modified sound produced by the heart-muscle and connected, as has
been suggested, with the altered conditions of the chordae tendinege and
papillary muscles, the normal action of which must be interfered with.
These physical signs, it is to be borne in mind, are characteristic only
of the stage in which compensation is maintained. Finally there comes a
period in which, with rupture of compensation, the presystolic murmur
disappears and there is heard in the apex region a sharp first sound, or
sometimes a gallop rhythm. The marked systolic shock may be present
after the disappearance of the thrill and the characteristic murmur. Un-
der treatment, with gradual recovery of compensation, probably with in-
creasing vigor of contraction of the right ventricle and left auricle, the
presystolic murmur reappears. In cases seen at this stage of the disease
the nature of the valve lesion may be entirely overlooked.
Stenosis of the mitral valve may for years be efficiently compensated
by the hypertrophy of the right ventricle. Many persons with the char-
acteristic physical signs of this lesion present no symptoms. They may
for years perhaps be short of breath on going up-stairs, but are al)le to pass
through the ordinary duties of life without discomfort. The pulse is
smaller in volume than normal, but may be perfectly regular. A special
danger of this stage is the recurring endocarditis. Vegetations may be
whif)pod off into the circulation and, blocking a cerebral vessel, may cause
hemiplegia or aphasia, or both. This, unfortunately, is not an uncommon
618 DISEASES OF THE CIRCULATORY SYSTEM.
sequence in women. Patients witli mitral stenosis may survive this acci-
dent for an indefinite period. A woman, over seventy 3'ears of age, died
in one of my wards at the Philadelphia Hospital, who had been in the
almshouse, hemiplegic, for more than thirty years. The heart presented
an extreme grade of mitral stenosis which had probably existed at the time
of the hemiplegic attack.
Failure of compensation brings in its train the group of symptoms
which have been discussed under mitral insufficiency. Briefly enumerated
they are : Rapid and irregular action of the heart, shortness of breath,
cough, signs of pulmonary engorgement, and very frequently haemoptysis.
Attacks of this kind may recur for j^ears. Bronchitis or a febrile attack
may cause shortness of breath or slight blueness. Inflammatory affections
of the lungs or pleura seriously disturb the right heart, and these patients
stand pneumonia very badly. Many, perhaps a majority of cases of mitral
stenosis, do not have dropsy. The liver may be greatly enlarged, and in
the late stages ascites is not uncommon, particularly in children. Gen-
eral anasarca is most frequently met with in those cases in which there
is secondary narrowing of the tricuspid orifice (Broadbent).
Tricuspid-Valve Disease.
(a) Tricuspid Regurgitation. — Occasionally this results from acute
or chronic endocarditis with puckering ; more commonly the condition is
one of relative insufficiency, and is secondary to lesions of the valves on
the left side, particularly of the mitral. It is met with also in all condi-
tions of the lungs which cause obstruction to the circulation, such as cir-
rhosis and emphysema, particularly in combination with chronic bron-
chitis. The symptoms are those of obstruction in the lesser circulation
with venous congestion in the systemic veins, such as has already been
described in connection with mitral insufficiency. The signs of this con-
dition are :
(1) Systolic regurgitation of the blood into the right auricle and the
transmission of the pulse-wave into the veins of the neck. If the regurgi-
tation is slight or the contraction of tlie ventricle is feeble there may be
no venous pulsation, but in other cases there is marked systolic pulsation
in the cervical veins. That in the right jugular is more forcible than
that in the left. It may be seen both in the internal and the external,
particularly in the latter. i\Iarked pulsation in these veins occurs only
when tlie valves guarding them become incompetent. Slight oscillations
are by no means uncommon, even when the valves are intact. The dis-
tention of the veins is sometimes enormous, particularly in the act of
coughing, when the right jugular at the root of the neck may stand out,
forming an extraordinarily prominent ovoid mass. Occasionally the re-
gurgitant pulse-wave may be widely transmitted and be seen in the sub-
clavian and axillary veins, and even in the subcutaneous veins over the
CHRONIC VALVULAR DISEASE. G19
shoulder, or, as in a case recently under observation, in the superficial
mammary veins.
Regurgitant pulsation through the tricuspid orifice may be transmitted
to the inferior cava, and so to the hepatic veins, causing a systolic disten-
tion of the liver. This is best appreciated by bimanual palpation, placing
one hand over the fifth and sixth costal cartilages and the other in the
lateral region of the liver in the mid-axillary line. The rhythmical ex-
pansile pulsation may be readily distinguished, as a rule, from the systolic
depression of the liver due to communicated pulsation from the left ven-
tricle.
(2) The second important symptom of tricuspid regurgitation is the
occurrence of a systolic murmur of maximum intensity in the lower ster-
num. It is usually a soft, low murmur, often to be distinguished from a
coexisting mitral murmur by differences in quality and pitch, and may be
heard to the right as far as the axilla. Sometimes it is very limited in its
distribution.
Together these two signs positively indicate tricuspid regurgitation.
In addition, the percussion usually shows increase in the area of dulness
to the right of the sternum, and the impulse in the lower sternal region is
forcible. In the great majority of cases the symptoms are those of the
associated lesions. In cirrhosis of the lung and in chronic emphysema the
failure of compensation of the right ventricle with insufficiency of the tri-
cuspid not infrequently leads either to acute asystole or to gradual failure
with cardiac dropsy.
(b) Tricuspid Stenosis. — This interesting condition may be either con-
genital or acquired. The congenital cases are not uncommon, and are
associated usually with other valvular defects which cause early death.
The acquired form is not very infrequent. Bedford Fenwick collected 46
observations, of which 41 were in women. Leudet* has analyzed 117
cases. Of 101 of these in which the ages were mentioned, 80 were in
women and 21 in men. A great majority of the cases were in adults, only
eight being between the ages of ten and twenty. Its rarity as an isolated
condition may be gathered from the fact that of 114 autopsies, in 11 only
was the lesion confined to this valve. In 21 the tricuspid, mitral, and
aortic segments were involved, and in 78 the tricuspid and mitral. Prac-
tically the condition is almost always secondary to lesions of the left heart.
The physical signs are sometimes characteristic. For instance, a pre-
systolic thrill has been noted by several observers. The percussion shows
dulness to be increased, particularly to the right of the sternum. ' On aus-
cultation a presystolic murmur has been determined in certain cases, and
is heard best at the root of the ensiform cartilage, or a little to tlie right
of it. Of general symptoms, cyanosis of the face and lips is very common,
and in the late stages, when dropsy supervenes, it is apt to be intense.
* Paris Thesis, 1888.
40
620 DISEASES OF THE CIRCULATORY SYSTEM.
The lesion is interesting chiefly because it forms one of the most serious
complications of mitral stenosis.
Pulmonary Valve Disease.
This is extremely rare.
(a) Stenosis is almost invariably a congenital anomaly. It constitutes
one of the most important of the congenital cardiac aifections. The valve
segments are usually united, leaving a small, narrow orifice. In the adult
cases occasionally occur. In Case 608 of my post-mortem records there
was extreme stenosis in a girl of eighteen, owing to great thickening and
adhesion of the segments, and there were also numerous vegetations. The
orifice was only two millimetres in diameter. The congenital lesion is
commonly associated with patency of the ductus Botalii and imperfection
of the ventricular septum. There may also be tricuspid stenosis.
The physical signs are extremely uncertain. There may be a systolic
murmur with a thrill heard best to the left of the sternum in the second
intercostal space. This murmur may be very like a murmur of aortic
stenosis, but is not transmitted into the vessels. Naturally the pulmonary
second sound is weak or obliterated, or may be replaced by a diastolic mur-
mur. Usually there is hypertrophy of the right heart.
(b) Pidmonary Insufficiency. — This rare affection is occasionally due
to congenital malformation, particularly fusion of two of the segments.
It is sometimes present, as Bramwell has shown, in cases of malignant
endocarditis.
The physical signs are those of regurgitation into the right ventricle,
but, as a rule, it is impossible to differentiate this from the murmur of
aortic insufficiency, though the maximum intensity may be in the pulmo-
nary area. In a recent case, in which two of the valve segments were
closely glued to the wall of the pulmonary artery owing to the projection
of an aneurism, a diastolic murmur developed under observation, which
w^as transmitted loudly down the sternum. The condition is extremely
rare and of little practical significance.
CoMBixED Valvular Lesions.
These are extremely common. The mitral and aortic segments may
be affected together ; next in frequency comes the combination of mitral
and tricuspid lesions ; and then of aortic, mitral, and tricuspid. Aortic
insufficiency or aortic stenosis is more frequently combined with mitral
incompetency than aortic stenosis with mitral stenosis, or mitral stenosis
with aortic insufficiency. In children the most common combination is
aortic and mitral insufficiency. In adults, mitral insufficiency with thick-
ening of the aortic valves and slight narrowing is jierhaps the most
common.
CnRONIC VALVULAR DLSEASE. 621
The diagnosis rests upon the chanictcr of tlie murmurs and the state
of the cliambers as regards hypertrophy and dihitation.
Prognosis in Valvular Disease. — The question is entirely one
of efficient compensation. So long as this is maintained the patient may
suffer no inconvenience, and even with the most serious forms of valve
lesion the function of the heart may be little, if at all, disturbed.
Practitioners who are not adepts in auscultation and feel unable to
estimate the value of the various heart murmurs should remember that
the best judgment of the conditions may be gathered from inspection
and palpation. With an apex beat in the normal situation and regular in
rhythm the auscultatory phenomena may be practically disregarded.
As Sir Andrew Clark states, a murmur j)er se is of little or no moment
in determining the prognosis in any given case. There is a large group
of patients who present no other symptoms than a systolic murmur heard
over the body of the heart, or over the apex, in whom the left ventricle is
not hypertrophied, the heart rhythm is normal, and who may not have
had rheumatism. Indeed, the condition is accidentally discovered, often
during examination for life insurance. I know cases of this kind which
have persisted unchanged for more than fifteen years Among the condi-
tions influencing prognosis are :
{a) Age. — Children under ten are bad subjects. Compensation is well
effected, and they are free from many of the influences which disturb
compensation in adults. The coronary arteries also are healthy, and
nutrition of the heart-muscle can be readily maintained. Yet, in spite
of this, the outlook in cardiac lesions developing in very young children
is usually bad. One reason is that the valve lesion itself is apt to be
rapidly progressive, and the limit of cardiac reserve force is in such cases
early reached. There seems to be proportionately a greater degree of
hypertrophy and dilatation. Among other causes of the risks of this
period are to be mentioned insufficient food in the poorer classes, the
recurrence of rheumatic attacks, and the existence of pericardial adhesions
The outlook in a child who can be carefully supervised and prevented
from damaging himself by overexertion is naturally better than in one
who is constantly overtasking his muscles. The valvular lesions which
develop at, or subsequent to, the period of puberty are more likely to be
permanently and efficiently compensated. Sudden death from heart-
disease is very rare in children.
(b) Sex. — Women bear valve lesions, as a rule, better than men, owing
partly to the fact that they live quieter lives, partly to the less common
involvement of the coronary arteries, and to the greater frequency of mit-
ral lesions. Pregnancy and parturition are disturbing factors, but are, I
think, less serious than some writers would have us believe.
{c) Valve affected.— T\\G relative prognosis of the different valve lesions
is very difficult to estimate. Each case must, therefore, be judged on its
own merits. Aortic insufficiency is unquestionably the most serious ; yet
022 DISEASES OF THE CIRCULATORY SYSTEM.
for years it may be perfectly compensated. Favorable circumstances in
any case are the moderate grade of hypertrophy and dilatation, the absence
of all symptoms of cardiac distress, and the absence of extensive arterio-
sclerosis and of angina. The prognosis rests in reality with the condition
of the coronary arteries. Eheumatic lesions of the valves, inducing insuf-
ficiency, are less apt to be associated with endarteritis at the root of the
aorta ; and in such cases the coronary arteries may escape for years. I
know a physician, now about thirty-five years of age, who, when sixteen,
had his first attack of rheumatism, which involved the aortic segments.
He has had two subsequent attacks of rheumatism, but with care has been
able to live a comfortable and fairly active life. On the other hand, when
the aortic insufficiency is only a part of an extensive arterio-sclerosis at the
root of the aorta, the coronary arteries are almost invariably involved, and
the outlook in such cases is much more serious. Sudden death is not un-
common, either from acute dilatation during some exertion, or, more fre-
quently, from blocking of one of the branches of the coronary arteries.
The liability of this form to be associated with angina pectoris also adds
to its severity. Aortic stenosis is a rare lesion, most commonly met with in
middle-aged or elderly men, and is, as a rule, well compensated. In many
cases it does not appear to limit the duration of life.
In mitral lesions the outlook on the whole is much more favorable
than in aortic insufficiency. Mitral insufficiency, when well compensated,
carries with it, perhaps, a better prognosis than mitral stenosis ; but it
must be borne in mind that the cases which last the longest are those in
which the valve orifice is more or less narrowed, as well as incompetent.
There is, in reality, no valve lesion so rapidly fatal and so poorly com-
pensated as that in which the mitral segments are gradually curled and
puckered until they form a narrow strip around a wide mitral ring — a con-
dition specially seen in children. There are many cases of mitral insuffi-
ciency in which the defect is thoroughly balanced for thirty or even forty
years, without distress or inconvenience. Even with great hypertrophy
and the apex beat almost in the mid-axillary line, there may be little or no
distress, and the compensation may be most eifective. Women may pass
safely through repeated pregnancies, though here they are liable to acci-
dents associated with the severe strain. I have had under my care for
many years a patient who had her first attack of rheumatism at the age of
fifteen, when she already had a well-marked mitral murmur. When she
first came under my observation, eighteen years ago, she had signs of
hypertrophy of the left ventricle with a loud systolic murmur. She has
had no cardiac disturbance whatever. She has lived a very active life, has
been unusually vigorous, has borne eleven children, and has passed through
three subsequent attacks of rheumatism.
In mitral stenosis the prognosis is usually regarded as less favorable.
My own experience has led me, however, to place this lesion almost on a
level, particularly in women, with the mitral insufficiency. It is found
CHRONIC VALVULAR DISEASE. 623
very often in persons in perfect health, who have had neither palpitation
nor signs of heart-failure, and who have lived laborious lives. The figures
given, too, by Broadbent indicate that the date of death in mitral stenosis
is comparatively advanced. These patients, too, pass through repeated
pregnancies with safety. There are of course those too common accidents,
the result of cerebral embolism, which are more liable to occur in this
than in other forms.
Hard and fast lines cannot be drawn in the question of prognosis in
valvular disease. Every case must be judged separately, and all the cir-
cumstances carefully balanced. There is no question which requires
greater experience and more mature judgment, and even the most ex-
perienced are sometimes at fault.
The following brief summary of the conditions which justify a favora-
ble prognosis embodies the large and varied clinical experience of Sir
Andrew Clark : Good general health ; just habits of living ; no excep-
tional liability to rheumatic or catarrhal affections ; origin of the valvular
lesion independently of degeneration ; existence of the valvular lesion
without change for over three years ; sound ventricles, of moderate fre-
quency and general regularity of action ; sound arteries, with a normal
amount of blood and tension in the smaller vessels ; free course of blood
through the cervical veins ; and, lastly, freedom from pulmonary, hepatic,
and renal congestion.
Treatment of Valvular Lesions. — For this purpose the valvu-
lar lesion may be divided into the period of progressive development, with
establishment and maintenance of hypertrophy, and the period of dis-
turbed compensation.
(a) Stage of Compensation. — Medicinal treatment at this period is not
necessary and is often hurtful. A very common error is to administer
cardiac drugs, such as digitalis, on the discovery of a murmur or of hyper-
trophy. If the lesion has been found accidentally, it may be best not to
tell the patient, but rather an intimate friend. Often it is necessary,
however, to be perfectly frank in order that the patient may take certain
preventive measures. He should lead a quiet, regulated, orderly life, free
from excitement and worry. An ordinary wholesome diet should be
taken, tobacco should be interdicted, and stimulants not allowed. Exer-
cise should be regulated entirely by the feelings of the patient. So long
as no cardiac distress or palpitation follows, moderate exercise will prove
very beneficial. The skin should be kept active by a daily bath. Hot
baths should be avoided and the Turkish bath should be interdicted. In
the case of full-blooded, somewhat corpulent individuals an occasional
saline purge should be taken. Patients with valvular lesions should not
go into very high altitudes. The act of coition has serious risks, particu-
larly in aortic insufficiency. Knowing that the causes which most surely
and powerfully disturb the compensation are overexertion, mental worry,
and malnutrition, the physician should give suitable instructions in each
024: DISEASES OF THE CIRCULATORY SYSTEM.
case. As it is always better to have the co-operation of an intelligent
patient, he should, as a rule, be told of the condition, but in this matter
the physician must be guided by circumstances, and there are cases in
whicli reticence is the Aviser policy.
(b) Stage of Broken Compensation. — The break may be immediate and
final, as when sudden death results from acute dilatation or from blocking
of a branch of the coronary artery. Among the first indications are short-
ness of breath on exertion or attacks of nocturnal dyspnoea. These are
often associated with impaired nutrition, particularly with anaemia, and a
course of iron or change of air may suffice to relieve the symj^toms.
Irregularity of the action of the heart cannot always be termed an in-
dication of failing compensation, particularly in instances of mitral disease.
It has greater significance in aortic lesions. Serious failure of compensa-
tion is indicated by signs of dilatation of the heart, the gallop rhythm, or
various forms of arrhythmia, with or without the existence of dropsy.
Under these circumstances the following measures are to be carried out :
(1) Best. — Disturbed compensation may be completely restored by rest
of the body. Both in Montreal and in Philadelphia it was a favorite dem-
onstration in practical therapeutics to show the influence of complete rest
and quiet on the cardiac dilatation. In many cases with oedema of the
ankles, moderate dilatation of the heart, and irregularity of the pulse, the
rest in bed, a few doses of the compound tincture of cardamoms, and a
saline purge suffice, within a week or ten days, to restore the compensa-
tion. One patient, in Ward 11 of the Montreal General Hospital, with
aortic insufficiency recovered from four successive attacks of failing com-
pensation by these measures alone.
(2) The relief of the embarrassed circulation.
(a) By Venesection. — In cases of dilatation, from whatever cause,
whether in mitral or aortic lesions or distention of the right ventricle in
emphysema, when signs of venous engorgement are marked and when
there is orthopnoea with cyanosis, the abstraction of from twenty to thirty
ounces of blood is indicated. This is the occasion in which timely vene-
section may save the patient's life. It is a condition in w^hich I have had
most satisfactory results from venesection. It is done much better early
than late. I have on several occasions regretted its postponement, par-
ticularly in instances of acute dilatation and cyanosis in connection with
emphysema.*
(/;) By Depletion throngh the Bozvels.— This is particularly valuable
when dropsy is present. Of the various purges the salines are to be pre-
ferred, and may be given by Matthew Hay's method. Half an hour to
an hour l)efore breakfast from half an ounce to an ounce and a half of
Epsom salts may be given in a concentrated form. This usually produces
* For ilkistrative cases from my wards see paper by H. A. Lafleur, Medical News,
Jiilv, 1891.
CrmONIC VALVULAR DISEASE. (525
from three to five liquid evacuations. The compound jalap powder in
half-drachm doses, or elaterium, may be employed for the same purpose.
Even when the pulse is very feeble these hydragogue cathartics are well
borne, and they deplete the portal system rapidly and efficiently.
(c) The Use of Remedies ivliich stimulate the HearVs Action. — Of
these, by far the most important is digitalis, which was introduced into
practice by Withering. The indication for its use is dilatation; the
contra-indication is a perfectly balanced compensatory hypertrophy, such
as we see in all forms of valvular disease. Broken compensation, no mat-
ter what the valve lesion may be, is the signal for its use. It acts upon
the heart, slowing and at the same time increasing the force of the pulsa-
tions. It acts on the peripheral arteries, raising their tension, so that a
steady and equable flow of blood is maintained in the capillaries, which,
after all, is the prime aim and object of the circulation. The beneficial
effects are best seen in cases of mitral disease with small, irregular pulse
and cardiac dropsy. Its effects are not less striking in the dilatation of
the left ventricle, in the failing compensation of aortic insufficiency or
of arterio-sclerosis. On theoretical grounds it has been urged that its use
is not so advantageous in aortic insufficiency, since it prolongs the diastole
and leads to greater distention. Practically, however, this need not be
considered, and, when given with care, digitalis is just as serviceable in
this as in any other condition associated with progressive dilatation. It
may be given as the tincture or the infusion. In cases of cardiac dropsy,
from whatever cause, fifteen minims of the tincture or half an ounce of
the infusion may be given every three hours for two days, after which the
dose may be reduced. Some prefer the tincture, others the infusion ; it
is a matter of indifference if the drug is good. The urine of a patient
taking digitalis should be carefully estimated each day. As a rule, when
its action is beneficial, there is within twenty-four hours an increase in
the amount ; often the flow is very great. Under its use the dyspnoea is
relieved, the dropsy gradually disappears, the pulse becomes firmer, fuller
in volume, and sometimes, if it has been very intermittent, regular.
Ill effects sometimes follow digitalis. There is no such thing as a
cumulative action of the drug manifested by sudden symptoms. Toxic
effects are seen in the production of nausea and vomiting. The pulse be-
comes irregular and small, and there may be two beats of the heart to one
of the pulse, which, as pointed out by Broadbent, is found particularly in
cases of mitral stenosis when they are under the influence of this drug.
The urine is reduced in amount. These symptoms subside on the with-
drawal ot the digitalis, and are rarely serious. There are patients who
take digitalis uninterruptedly for years, and feel palpitation and distress if
the drug is omitted. \\\ mitral disease, even when it does good it does not
always steady the pulse. There are many cases in which the irregularity
is not affected by the digitalis. When the compensation has been re-
established the drug may be omitted. When there is dyspnoea on exer-
626 DISEASES OF THE CIRCULATORY SYSTEM.
tion and cardiac distress, from five to ten minims three times a day may
be advantageously given for prolonged periods, but the effects should be
carefully watched. In cardiac dropsy digitalis should be used at the out-
set with a free hand. Small doses should not be given, but from the first
half-ounce doses of the infusion every three hours, or from fifteen to
twenty minims of the tincture. There are no substitutes for digitalis.
Of other remedies strophanthus alone is of service. Given in doses
of from five to eight minims of the tincture, it acts like digitalis. It cer-
tainly will sometimes steady the intermittent heart of mitral valve disease
when digitalis fails to do so, but it is not to be compared with this drug
when dropsy is present. Convallaria, citrate of caffeine, and adonis ver-
nalis are warmly recommended as substitutes for digitalis, but their infe-
riority is so manifest that their use is rarely indicated.
There are two valuable adjuncts in the treatment of valvular disease —
iron and strychnia. When anaemia is a marked feature iron should be
given in full doses. In some instances of failing compensation iron is the
only medicine needed to restore the balance. Arsenic is occasionally an
excellent substitute, and one or other of them should be administered in
all instances of heart-trouble when pallor is present. Strychnia is a heart
tonic of very great value. It may be given in combination with the digi-
talis in one or two drop doses of the one per cent solution.
Treatment of Special Symptoms, {a) Dropsy. — The increased
arterial tension and activity of the capillary circulation under the influ-
ence of digitalis hastens the interstitial lymph flow and favors resorption
of the fluid. The hydragogue cathartics, by rapidly depleting the blood,
promote the absorption of the fluid from the lymph spaces and the lymph
sacs. These two measures usually suffice to rid the patient of the dropsy.
In some cases, however, it cannot be relieved, and then Southey's tubes
may be used or the legs punctured. If done with care, after a thorough
washing of the parts, and if antiseptic precautions are taken, scarification
is a very serviceable measure, and should be resorted to more frequently
than it is. Canton-flannel bandages may be applied on the oedematous
legs.
{h) Dyspnoea. — The patients are usually unable to lie down. A com-
fortable bed-rest should therefore be provided — if possible, one with lateral
projections, so that in sleeping the head can be supported as it falls over.
The shortness of breath is associated with dilatation, chronic bronchitis,
or hydrothorax. The chest should be carefully examined in all these
cases, as hydrothorax of one side or of both is a common cause of short-
ness of breath. T'here are cases of mitral regurgitation with recurring
hydrothorax as the sole dropsical symptom, which is relieved, week by
week or month by month, by tapping. For the nocturnal dyspnoea, par-
ticularly when combined with restlessness, morphia is invaluable and may
be given without hesitation. The value of the calming influence of opium
in all conditions of cardiac insufficiency is not enough recognized. There
CHRONIC VALVULAR DISEASE. 627
are instances of cardiac dyspnoea unassociated with dropsy, particularly in
mitral-valve disease, in which nitroglycerin is of great service, if given in
the one per cent solution in increasing doses. It is especially serviceable
in the cases in which the pulse tension is high.
(c) Palpitation and Cardiac Distress. — In instances of great hyper-
trophy and in the throbbing which is so distressing in some cases of
aortic insufficiency^ aconite is of service in doses of from one to three
minims every two or three hours. An ice-bag over the heart or Leiter's
coil is also of service in allaying the rapid action and the throbbing. For
the pains, which are often so marked in aortic lesions, iodide of potassium
in ten grain doses, three times a day, or the nitroglycerin may be tried.
Small blisters are sometimes advantageous. It must be remembered that
an important cause of palpitation and cardiac distress is flatulent disten-
tion of the colon, against which suitable measures must be directed.
(d) Gastric Symptoms. — The cases of cardiac insufficiency which do
badly and fail to respond to digitalis are most often those in whjch nausea
and vomiting are prominent features. The liver is often greatly enlarged
in these cases ; there is more or less stasis in the hepatic vessels, and but
little can be expected of drugs until the venous engorgement is relieved.
If the vomiting persists, it is best to stop the food and give small bits of
ice, small quantities of milk and lime water, and effervescing drinks, such
as Apollinaris water and champagne. Creosote, hydrocyanic acid, and the
oxalate of cerium are sometimes useful ; but, as a rule, the condition is
obstinate and always serious.
{e) Co^lfJll and Hmmoptysis. — The former is almost a necessary con-
comitant of cardiac insufficiency, owing to engorgement of the vessels
and more or less bronchitis. It is allayed by measures directed rather to
the heart than to the lungs. Haemoptysis in chronic valvular disease is
sometimes a salutary symptom. An army surgeon, who was invalided
during the late civil war on account of haemoptysis, supposed to be due
to tuberculosis, has since that time had, in association with mitral insuffi-
ciency and enlarged heart, many attacks of haemoptysis. He assures me
that his condition is invariably better after the attack. It is rarely fatal,
except in some cases of acute dilatation, and seldom calls for special treat-
ment.
(/) Sleeplessness. — One of the most distressing features of valvular
lesions, even in the stage of compensation, is disturbed sleep. Patients
may wake suddenly with throbbing of the heart, often in an attack of
nightmare. Subsequently, when the compensation has failed, it is also a
worrying symptom. The sleep is broken, restless, and frequently dis-
turbed by frightful dreams. Sometimes a dose of the spirits of chloro-
form or of etlier, with half a drachm of spirits of camphor, given in a
little hot whisky, will give a quiet night. The compound spirits of ether,
Hoffman's anodyne, though very unpleasant to take, is frequently a great
boon in the intermediate period when compensation has partially failed
628 DISEASES OF THE CIRCULATORY SYSTEM.
and the patients suffer from restless and sleepless nights. Paraldehyde
and amylene hydrate are sometimes serviceable. Urethan, sulphonal,
and chloralamide are rarely efficacious, and it is best, after a few trials,
particularly if the paraldehyde does not answer, to give morphia. It may
be given in combination with atropine.
{(/) Renal Symjitoms. — AVith ruptured compensation and lowering of
the tension in the aorta, the urinary secretion is greatly diminished, and
the amount may sink to five or six ounces in the day. Digitalis and
strophanthus, when efficient, usually increase the flow. A brisk purge
may be followed by augmented secretion. The combination in pill form
of digitalis, squill, and the black oxide of mercury, will sometimes prove
effective when the infusion or tincture of digitalis alone has failed. Calo-
mel acts well in some cases, given in grs. iij every six hours for three or
four days.
The diet in chronic valve diseases is often very difficult to regulate.
With the dilatation and venous engorgement come nausea and often a
great distaste for food. The amount of liquid should be restricted, and
milk, beef-juice, or egg albumen given every three hours. When the
serious symptoms have passed, eggs, scraped meat, fish, and fowl may be
allowed. Starchy foods, and all articles likely to cause flatulency, should
be forbidden. Stimulants are usually necessary, either whisky or brandy.
III. HYPERTROPHY AND DILATATION.
Hypertrophy is an enlargement of the heart due to an increased thick-
ness, total or partial, in the muscular walls. Dilatation is an increase in
size of one or more of the chambers with or without thickening of the
walls. The conditions usually coexist, and could be more correctly de-
scribed together under the term enlargement of the heart. Simple hyper-
trophy, in which the cavities remain of a normal size and the walls are
increased, occurs, but simple dilatation, in which the cavities are increased
and the walls remain of a normal diameter, probably does not, as it is
always associated with thinning or with thickening of the coats. Com-
monly we have the forms of simple hy]iertropliy, hypertrophy with dilata-
tion, and dilatation with thinning of the coats.
Hypertrophy of the Heart.
There are two forms — the simple hypertrophy, in which the cavity or
cavities are of normal size ; and hypertroj^hy with dilatation (eccentric
hypertrophy), in which the cavities are enlarged and the walls increased
in tliickness. Tlie condition formerly spoken of as concentric h\"per-
trophy, in which there is diminution in the size of the cavity with thick-
ening of the walls, is, as a rule, a post-mortem change.
HYPERTROPnY AND DILATATION. 029
The enlargement may affect the entire organ, one side, or only one
chamber. Naturally, as the left ventricle does the chief work in forcing
the blood through the systemic arteries, the change is most frequently
found in it.
Etiology. — Hypertrophy of the heart follows the law governing
muscles, that within certain limits, if the nutrition is kept up, increased
work is followed by increased size — i. e., h3rpertrophy. Hypertrophy of
the left ventricle alone, or with general enlargement of the heart, is
brought about by —
Conditions affecting the heart itself : (1) Disease of the aortic valve ;
(2) mitral insufficiency; (3) general pericardial adhesions; (4) sclerotic
myocarditis; (5) disturbed innervation, with overaction, as in exophthal-
mic goitre, in long-continued nervous palpitation, and as a result of the
action of certain articles, such as tea, alcohol, and tobacco. In all of these
conditions the work of the heart is increased. In the case of the valve
lesions the increase is due to the increased intraventricular pressure ; in
the case of the adherent pericardium and myocarditis, to direct interference
with the symmetrical and orderly contraction of the chambers.
Conditions acting upon the blood-vessels : (1) General arterio-sclerosis,
with or without renal disease ; (2) all states of increased arterial tension
induced by the contraction of the smaller arteries under the influence of
certain toxic substances, which act, as Bright suggested, by affecting " the
minute capillary circulation, render greater action necessary to send the
blood through the distant subdivisions of the vascular system " ; (3) pro-
longed muscular exertion, which enormously increases the blood-pressure
in the arteries ; (4) narrowing of the aorta, as in the congenital stenosis.
Hypertrophy of the right ventricle is met with under the following
conditions —
(1) Lesions of the mitral valve, either incompetence or stenosis, which
act by increasing the resistance in the pulmonary vessels. (2) Pulmonary
lesions, obliteration of any number of blood-vessels within the lungs, such
as occurs in emphysema or cirrhosis, is followed by hypertrophy of the
right ventricle. (3) Valvular lesions on the right side occasionally cause
hypertropliy in the adult, not infrequently in the foetus. (4) Chronic
valvular disease of the left heart and pericardial adhesions are sooner or
later associated with hypertrophy of the right ventricle.
In the auricles simple hypertrophy is never seen ; it is always dilata-
tion with hypertrophy. In the left auricle the condition develops in lesions
at the mitral orifice, particularly stenosis. The right auricle hypertrophies
when there is greatly increased blood-pressure in the lesser circulation,
whether due to mitral stenosis or pulmonary lesions. Narrowing of the
tricuspid orifice is a loss frequent cause.
Morbid Anatomy. — The heart of an average-sized man weighs
about nine ounces (280 grammes) ; that of a woman, about eight ounces
(250 grammes). In cases of general hypertrophy the heart may weigh
(^30 DISEASES OF THE CIRCULATORY SYSTEM.
from sixteen to twenty ounces. AYeights above twenty-j&ve ounces are rare.
So far as I know, the heaviest heart on record is one described by Beverly
Robinson, weighing fifty-three ounces. Dulles has reported one weighing
forty-eight ounces. The measurement of the thickness of the walls is,
next to weighing, the best means of determining the hypertrophy. In
extreme dilatation the walls, though actually thickened, may look thin.
When rigor mortis is present, the cavity may be small and the walls may
appear greatly thickened. The measurements should not be made until
the heart has been soaked in w^ater and thoroughly relaxed. In the left
ventricle a thickness of ten lines, or from twenty to twenty-five millimetres,
indicates hypertrophy. The right ventricle is thinner than the left, and
has an average diameter of from four to seven millimetres. In hyper-
trophy it may measure from thirteen to twenty millimetres. The left
auricle has a normal thickness of about three millimetres, which may be
doubled in hypertrophy. The wall of the right auricle is thinner than
that of the left, rarely exceeding two millimetres in diameter. The appen-
dices of the auricles often present marked increase in thickness and the
musculi pectinati are greatly developed.
The shape of the heart is altered in hypertrophy ; with great enlarge-
ment of the ventricles, the apex is broadened, and the conical shape is lost.
In the enormous enlargement of aortic insufficiency this rotundity of the
apex is very marked. \Yhen the right ventricle is chiefly affected it occu-
pies the largest share of the apex. In mitral stenosis the contrast is very
striking between the large, broad right ventricle, reaching to the apex,
and the small left chamber.
The hypertrophied muscle has a deep red color, is firm, and is cut with
increasing resistance. The right ventricle, as Kokitansky noted, may have
a peculiar hard, leathery consistence. In simple hypertrophy of the left
ventricle the papillary muscles and the columnae carnese may be enlarged,
but the former are often much flattened in dilated hypertrophy. The
muscular trabeculae are more developed, as a rule, in the right ventricle
than in the left.
The increase in size of the heart is probably due to a definite numerical
increase, resulting from development of new fibres.
Symptoms. — Hypertrophy is a conservative process, secondary to
some valvular or arterial lesion, and is not necessarily accompanied by
symptoms. So admirable is the adjusting power of the heart that, for
example, an advancing stenosis of aortic or mitral orifice may for years be
perfectly equalized by a progressive hypertrophy, and the subject of the
affection be happily unconscious of the existence of heart-trouble. Hyper-
trophy is in almost all cases an unmixed good ; the symptoms which arise
are usually to be attributed to its failure, or, as we say, to disturbance of
compensation.
Among the most common symptoms are unpleasant feelings about the
heart — a sense of fulness and discomfort, rarely amounting to pain. This
HYPERTROPHY AND DILATATION. 03t
may be very noticeable when the patient is recumbent on the left side.
Actual pain is rare, except in the irritable heart from tobacco or in neur-
asthenics. Palpitation may not occur, nor do patients always have sen-
sations from the violent shocks of a greatly hypertrophied. organ. There
are instances in which very uneasy feelings arise from a moderately exag-
gerated, pulsation. The general condition has much to do with this. In
health we are not conscious of the heart's pulsations, but one of the first
indications of exhaustion from excesses or overstudy is the consciousness
of the heart's action, not necessarily with palpitation. Headaches, flush-
ings of the face, noises in the ears, and flashes of light may be present.
Certain untoward effects of long-continued hypertrophy of the left
ventricle must be mentioned, chief among which is the production of
arterio-sclerosis. Particularly is this the case when the hypertrophy re-
sults from increased peripheral resistance. The heightened blood-pressure
(expressed by the word strain) in the arteries gradually induces an endar-
teritis and a stiff, inelastic state of those vessels most exposed to it — viz.,
the aorta and its primary divisions. In overcoming the peripheral ob-
struction the hypertrophy " ruins the arteries as a sequential result "
(Fothergill). Prolonged muscular exertion also acts injuriously in this
way.
Another danger is rupture of the blood-vessels, particularly those of the
brain. In general arterial degeneration associated with contracted kidneys
and hypertrophied left heart apoplexy is common. Indeed, in the majority
of cases of cerebral haemorrhage there is sclerosis of the smaller vessels,
often with the development of miliary aneurisms, and the rupture may be
caused by the forcible action of the heart.
Physical Signs. — Inspection may show bulging of the prsecordia, pro-
ducing in children marked asymmetry of the chest. It may occur with-
out pericardial adhesions, which Schroetter thinks are invariably associated
with this condition. The intercostal spaces are widened, and the area of
visible impulse is much increased. On palpation the impulse is forcible
and heaving, and with each systole the hand or the ear applied over the
heart may be visibly raised. A sIoav, heaving impulse is one of the best
signs of simple hypertrophy. With large dilated hypertrophy the forcible
impulse is often more sudden and abrupt. A second, weaker impulse can
sometimes be felt, due perhaps to a rebound from the aortic valves (Gowers).
The beat may be felt in the sixth, seventh, or eighth interspace from one
to three inches outside the nipple. This downward dislocation of the
apex is an important sign in hypertrophy of the left ventricle. In moder-
ate grades, such as are seen in chronic Bright's disease, the impulse may be
in the sixth interspace in the nipple line, or a little outside of it.
PercuHsion reveals increased dulness, which in the parasternal line
may begin at the third rib or in the second interspace, and transversely
may extend from half an inch to two inches beyond the nipple line and
an equal distance beyond the middle line of the sternum. The dull area
(532 DISEASES OF THE CIRCULATORY SYSTEM.
is more ovoid than in healtli. "When carefully delimited the colossal
h}'pertrophy of aortic valve disease may give an area of dulness from seven
to eight inches in transverse extent. In moderate grades a transverse
dulness of four inches is not uncommon.
On aiiScuUation the sounds, when the valves are healthy, may present
no special changes, but the first sound is often prolonged and dull.
When there is dilatation as well, it may be very clear and sharp. Redu-
plication is common in the hypertrophy of renUl disease. A peculiar clink
— the tintemeiit metallique of Bouillaud — may be heard just to the right
of the apex beat. The second sound is clear and loud, sometimes ringing
in character or reduplicated. With valvular lesions, the sounds, of course,
are much altered, and are replaced or accompanied by murmurs.
In simple hypertrophy not dependent on valvular lesions, the pulse
is usually regular, full, strong, and of high tension. It may be in-
creased in rapidity, but is often normal. In eccentric hypertrophy the
pulse is full, but softer, and usually more rapid. One of the earliest signs
of failure and dilatation is irregularity and intermittence of the pulse.
Hypertrophy of the right ventricle in the adult very rarely follows
valvular disease on the right side, but results from increased resistance in
the pulmonary circulation, as in cirrhosis of the lung and emphysema, or
in stenosis of the mitral orifice. With perfect compensation, which fully
maintains the equilibrium of the circulation, there are no symptoms.
Extra exertion, as the ascent of stairs or running, may cause shortness of
breath, but in many ways hypertrophy of the right ventricle is the most
enduring and salutary form in the whole cycle of cardiac affections. For
long periods of years the effects of mitral stenosis may be counterbalanced,
and only sudden death by accident or an acute disease reveal the existence
of an unsuspected lesion. In the hypertrophy secondary to emphysema
or cirrhosis of the lungs, there may be sensations of distress in the cardiac
region, with cough and shortness of breath ; but as long as the dilatation
is moderate the symptoms are not marked. With great dilatation and
tricuspid leakage come venous engorgement, oedema, and pulmonary
troubles. The increased pressure in the lesser circulation leads to sclerosis
of the pulmonary arteries and the constant engorgement of the capillaries
leads ultimately to a deposition of pigment and increase in the fibrous
elements in the lung — the brown induration. Extreme pulmonary con-
gestion and apoplexy are more often associated with dilatation. Haemop-
tysis may result from rupture of vessels during sudden exertion.
Physical Signs. — Bulging of the lower part of the sternum and left
cartilages occurs. The apex beat is forced to the left, but is not so often
displaced downward. The most marked impulse may be in the angle
between the ensiform cartilage and the seventh rib or beneath tlie carti-
lages of tlie sixtli and seventh ribs. The pulsation is rather diffuse,
not punctuate, particularly if there is much dilatation. In thin-walled
chests there may be pulsation in the third and fourth right interspaces.
HYPERTROPHY AND DILATATION. C33
The cardiac clulness is increased transversely and toward the right; it
may extend an inch or more beyond the border of the sternum. On
auscultation the first sound at the lower part of the sternum is louder and
fuller than normal, but the differences are not very marked unless there
is much dilatation, when the sound is clearer and sharper. Accentuation
and reduplication of the second sound are heard in the pulmonary artery
on account of the increased tension. The pulse at the wrist is usually small.
Pulsation occurs in the jugulars when there is tricuspid incompetence.
Hypertrophy of the auricles always occurs with dilatation. It is most
common in the left chamber, which hypertrophies in mitral stenosis and
incompetency and naturally assists in restoring the balance of the circu-
lation. There are no distinctive physical signs, and we usually can infer
its presence only by the existence of mitral stenosis and a presystolic mur-
mur. Increased dulness may be determined to the left of the sternum,
and there may be a presystolic wave in the second left interspace.
Hypertrophy and dilatation of the right auricle are met with (associ-
ated with a similar condition in the right ventricle and incompetency
of the tricuspid) in emphysema, cirrhosis of the lung, chronic bronchitis,
and mitral disease. In comparison with the left auricle the greater de-
velopment and h3rpertrophy of the appendix and its musculi pectinati is
very striking. The latter may be distributed over the anterior wall of
the sinus to a greater extent than in health. There are increased dulness
in the third and fourth interspaces, pulsation sometimes presystolic in
rhythm, signs of venous engorgement, jugular pulsation, and other evi-
dences of dilatation of the right heart.
Diagnosis. — Among conditions to be distinguished are :
(1) Xeurotic palpitation, from whatever cause, even when very forci-
ble, has not the heaving impulse of genuine hypertrophy. Enlargement
of the organ may, however, follow prolonged overaction, as in the smoker's
heart, the irritable heart of neurasthenics, and in exophthalmic goitre, but
it is usually slight.
(2) The increased area of dulness may be due to a variety of causes,
some of which may closely simulate hypertrophy, such as pericardial effu-
sion, aneurism, mediastinal growths, or displacement of the heart from
pressure, or the existence of malformation of the chest. With the exer-
cise of ordinary care, however, the diagnosis can usually be made. There
are two opposite conditions which frequently give trouble. With the left
lung contracted from pleurisy, phthisis, or cirrhosis, a large surface of the
heart is exposed ; the pulsation may be extensive and forcible, and may at
first sight resemble hypertrophy. In this condition there is dislocation
upward and to the left. The existence of pulmonary or pleuritic disease
and tlie fixation of the lung on deep inspiration will suffice to prevent
mistakes. A less extensive exposure of the heart may occur without any
disease in very narrow-chested persons with ill-developed lungs; here,
though the area of dulness may be much increased, the normal position
034: DISEASES OF THE CIRCULATORY SYSTEM.
of the apex, the absence of forcible, heaving impulse, and of any obvious
cause of hypertrophy will afford satisfactory criteria for a diagnosis. The
reverse condition exists in some cases in which emphysema masks moder-
ate cardiac hypertrophy. The area of dulness may be normal, or even
diminished, and the pulse and character of the sounds will help in the
diagnosis ; but it is sometimes a difficult matter.
Prognosis. — The course of any case of cardiac hypertrophy may be
divided into three stages :
(a) The period of development, which varies with the nature of the
primary lesion. For example, in rupture of an aortic valve, during a sud-
den exertion, it may require months before the hypertrophy becomes fully
developed ; or, indeed, it may never do so, and death may follow from an
uncompensated dilatation. On the other hand, in sclerotic affections of
the valves, with stenosis or incompetency, the hypertrophy develops step
by step with the lesion, and may continue to counterbalance the progress-
ive and increasing impairment of the valve.
(b) The period of full compensation — the latent stage — during which
the heart's vigor meets the requirements of the circulation. This period
may last an indefinite time, and a patient may never be made aware by
any symptoms that he has a valvular lesion.
(c) The period of broken compensation, which may come on suddenly
during very severe exertion. Death may result from acute dilatation ;
but more commonly it takes place slowly and results from degeneration
and weakening of the heart-muscle.
The breaking or rupture of cardiac compensation may be induced by
many causes, among which the most important are : (1) Failure of the
general nutrition. In many instances of heart-disease, exposure, poor
food, and alcohol combine to bring about disturbance of a well-balanced
heart lesion. Acute illnesses, particularly the fevers, may induce general
debility and with it weakening of the heart-muscle. (2) Disturbance of
the local nutrition of the heart, owing to gradual sclerosis of the coronary
arteries, is a common cause. (3) Very severe muscular exertion, which may
disturb a compensation, perfect for years, and induce death in a few days
(Traube). (-l) Mental emotions. Severe grief or fright may bring on
failure of compensation.
The prognosis is largely, as already stated, a matter of maintained
compensation. Once established, the hypertrophy rarely, if ever, disap-
pears, inasmuch as the cause usually persists. Occasionally, perhaps, the
hypertrophy associated with neurotic palpitation from tobacco, or other
causes, or the hypertrophy following muscular over-exertion, may dis-
appear.
HYPERTROPHY AND DILATATION. 635
Dilatation of the Heakt.
Two varieties are recognized, dilatation with thickening and dilata-
tion with thinning. The former is the most common, and corresponds to
the dilated or eccentric hypertrophy.
Etiology. — Two important causes combine to produce dilatation —
increased pressure within the cavities and impaired resistance, due to
weakening of the muscular wall — which may act singly, but are often
combined. A weakened wall may yield to a normal distending force, or
a normal wall may yield under a heightened blood-pressure.
(1) Heightened endocardiac pressure results either from an increased
quantity of blood to be moved or an obstacle to be overcome, and is the
most frequent cause. It does not necessarily bring about dilatation ; sim-
ple hypertrophy may follow, as in the early period of aortic stenosis, and
in the hypertrophy of the left ventricle in Bright's disease.
A majority of the important causes of increased endocardiac pressure
have already been discussed under hypertrophy. One or two may be con-
sidered more in detail.
The size of the cardiac chambers varies in health. With slow action
of the heart the dilatation is complete and fuller than it is with rapid
action. Physiologically, the limits of dilatation are reached when the
chamber does not empty itself during the systole. This may occur as an
acute, transient condition in severe exertion — during, for example, the
ascent of a mountain. There may be great dilatation of the right heart,
as shown by the increased epigastric pulsation, and even increase in the
cardiac dulness. The safety-valve action of the tricuspid valves may here
come into play, relieving the lungs by permitting regurgitation into
the auricle. With rest the condition is removed, but if it has been ex-
treme, the heart may suffer a strain from which it may recover slowly, or,
indeed, the individual may never be able again to undertake severe exer-
tion. In the process of training, the getting wind, as it is called, is
largely a gradual increase in the capability of the heart, particularly of
the right chambers. A degree of exertion can be safely maintained in
full training which would be quite impossible under other circumstances,
because by a gradual process of what we may call physical education the
heart has strengthened its reserve force — widened enormously its limits of
physiological work. Endurance in prolonged contests is measured by the
capabilities of the heart, and its essence consists in being able to meet the
continuous tendency to overstep the limits of dilatation.
AVe have no positive knowledge of the nature of the changes in the
heart which occur in this process, but it must be in the direction of
increased muscular and nervous energy. The large heart of atliletcs may
be due to the prolonged use of their muscles, but no man becomes a
great runner or oarsman who has not naturally a capable if not a large
heart. Master McGrath, the celebrated greyhound, and Eclipse, the
41
(536 DISEASES OF THE CIRCULATORY SYSTEM.
race-horse, both famous for endurance rather than speed, had very large
hearts.
Excessive dilatation during severe muscular effort results in heart-
strain. A man, perhaps in poor condition, calls upon his heart for extra
work during the ascent of a high mountain, and is at once seized with
pain about the heart and a sense of distress in the epigastrium. He
breathes rapidly for some time, is " puffed," as we say, but the symptoms
pass off after a night's quiet. An attempt to repeat the exercise is fol-
lowed by another attack, or, indeed, an attack of cardiac dyspnoea may
come on while he is at rest. For months such a man may be unfitted for
severe exertion, or he may be permanently incapacitated. In some way he
has overstrained his heart and become " broken-winded." Exactly what
has taken place in these hearts we cannot say, but their reserve force is
lost, and with it the power of meeting the demands exacted in maintain-
ing the circulation during severe exertion. The " heart-shock " of Latham
includes cases of this nature — sudden cardiac breakdown during exertion,
not due to rupture of a valve. It seems probable that sudden death in
men during long-continued efforts, as in a race, is sometimes due to over-
distention and paralysis of the heart.
Examples of dilatation occur in all forms of valve lesions. In aortic
incompetency blood enters the left ventricle during diastole from the
unguarded aorta and from the left auricle, and the quantity of blood at
the termination of diastole subjects the walls to an extreme degree of
pressure, under which they inevitably yield. In time they augment in
thickness, and present the typical eccentric hypertrophy of this condition.
In mitral insufficiency blood which should have been driven into the
aorta is forced into and dilates the auricle from which it came, and then
in the diastole of the ventricle a large amount is returned from the auri-
cle, and with increased force. In mitral stenosis the left auricle is the
seat of greatly increased tension during diastole, and dilates as well as
hypertrophies ; the distention, too, may be enormous. Dilatation of the
right ventricle is produced by a number of conditions, which were con-
sidered under hypertrophy. All circumstances, such as mitral stenosis,
emphysema, etc., which permanently increase the tension of the blood in
the pulmonary vessels, will cause its dilatation.
(2) Impaired nutrition of the heart-walls may lead to a diminution of
the resisting power so that dilatation readily occurs.
The loss of tone due to parenchymatous degeneration or myocarditis
in fevers may lead to a fatal condition of acute dilatation. It is a recog-
nized cause of death in scarlatinal dropsy (Goodhart), and may occur in
rlieuraatic fever, typhus, typhoid, erysipelas, etc. The changes in the
heart-muscle wliich accompany acute endocarditis or pericarditis may lead
to dilatation, especially in the latter disease. In anaemia, leukemia, and
chlorosis the dilatation may be considerable. In sclerosis of the walls, the
yielding is always where this process is most advanced, as at the left apex.
nYPERTROPIIY AND DILATATION. 0,37
Under any of those circumstances the walls may yield with normal blood-
pressure.
Pericardial adhesions are a cause of dilatation, and we generally find
in cases with extensive and firm union considerable hypertrophy and dila-
tation. There is usually here some impairment as well of the superficial
layers of muscle.
Morbid Anatomy. — The condition usually exists with hypertrophy
in two or more chambers. It is more common on the right than on the
left side. The most extreme dilatation is in cases of aortic incompetency,
in which all the cavities may be enormously distended. In mitral stenosis
the left auricle is often trebled in capacity, and the right chambers also are
very capacious. The auricles may contain from eighteen to twenty ounces
of blood. In chronic lesions of the lungs the right chambers are chiefly
involved. In great distention of one ventricle the septum may bulge
toward the other side. The auriculo-ventricular rings are often dilated,
and there may be an increase in the circumference of an inch and a half
or even two inches. Thus, the tricuspid orifice, the circumference of
which is about four and a half inches, may freely admit a graduated heart-
cone of over six inches ; and the mitral orifice, which normally is about
three and a half inches, may admit the cone to five and a half inches or
even more. Great dilatation is always accompanied with relative incom-
petency of the valves, so that free regurgitation into the auricles is per-
mitted. The orifices of the venaa cavse and of the pulmonary veins may
be greatly dilated.
The endocardium is often opaque, particularly that of the auricles.
The muscle substance varies according to the presence or absence of de-
generations. The microscope may show marked fatty or parenchymatous
change, but in some instances no special alteration may be noticeable.
There is much truth in Niemeyer's assertion " that it is not possible by
means of the microscope to recognize all the alterations of the muscular
fibrillae which diminish the functional power of the heart." Of the
changes in the ganglia of the heart we know very little. As centres of
control they probably have more to do with cardiac atony and breakdown
than we generally admit. Degeneration of them has been noted by Put-
jakin, Ott, and others.
Symptoms and Physical Signs. — Dilatation causes weakness of
the cardiac walls, diminishes the vigor of their contractions, and is there-
fore the reverse of hypertrophy. So long as compensation is maintained
the enlargement of a cavity may be considerable. The limit is reached
when the hypertrophied walls in the systole can no longer expel all the
contents, part of which remain, so that at each diastole the chamber is
abnormally full. Thus, in aortic incompetency blood enters the left ven-
tricle from the aorta as well as the auricle ; dilatation ensues, and also
hypertrophy as a direct effect of the increased pressure and increased
amount of blood to be moved. But if from any cause the hypertrophy
638 DISEASES OF THE CIRCULATORY SYSTEM.
weakens and the ventricle during systole fails to empty itself completely,
a still larger amount is in it at the end of each diastole, and the dilatation
becomes greater. The amount remaining after systole prevents the blood
from entering freely from the auricle. Incompetency of the auriculo-
ventricular valves follows, with dilatation of the auricle and impeded
blood-flow in the pulmonary veins. Dilatation and hypertrophy of the
right heart may compensate for a time, but when this fails the venous
system becomes engorged and dropsy may result. The consideration of
the symptoms of chronic valvular lesions is largely that of dilatation and
its effects. Acute dilatation, such as we see in fevers or in sudden failure
of a hypertrophied heart, is accompanied by three chief symptoms — weak,
usually rapid, impulse, dyspnoea, and signs of obstructed venous circula-
tion. Cardiac pain may be present, but is often absent.
The physical signs of dilatation are those of a weak and enlarged
organ. The impulse is diffuse, often undulatory, and is felt over a wide
area, and an apex beat or a point of maximum intensity may not exist.
When it does exist, it may be visible and yet cannot be felt — a valuable
observation made by Walshe. An extensive area of impulse with a quick,
weak maximum apex beat may be present. When the right heart is
chiefly dilated the left may be pushed over so as to occupy a much less ex-
tensive area in front of the heart, and the true apex beat cannot be felt ;
but the chief impulse is just below, or to the right of, the xiphoid carti-
lage, and there is a wavy pulsation in the fourth, fifth, and sixth inter-
spaces to the left of the sternum. In extreme dilatation of the right
auricle a pulsation may sometimes be seen in the third right interspace
close to the sternum, and with free tricuspid regurgitation this may be
systolic in character. Whether the pulsation frequently seen in the sec-
ond left interspace is ever due to a dilated left auricle has not been deter-
mined- I have sometimes thought it was presystolic in rhythm, though
it may be distinctly systolic. Post mortem, it is rare in the most extreme
distention to see the auricular appendix so far forward as to warrant the
belief that it could beat against the second interspace. The area of dul-
ness is increased, but an emphysematous lung or the fully distended organ
in a state of brown induration may cover over the heart and greatly limit
the extent. The directions of increase were considered in connection with
hypertrophy.
The first sound is shorter, sharper, more valvular in character, and
more like the second. As the dilatation becomes excessive it gets weaker.
Reduplication is not common, but occasionally differences may be heard
in the first sound over the right and left hearts. The sounds are fre-
quently obscured by murmurs, which are produced by incompetency of
the valves due to the great dilatation, or are associated with the chronic
valve disease on which the condition depends. The aortic second sound
is replaced by a murmur in aortic regurgitation. The pulmonary sound
is accentuated in mitral regurgitation and pulmonary congestion, but
HYPERTROPHY AND DILATATION. 639
with extreme dilatation it may be mucli weakened. The heart's action
is irregular and intermittent, and the pulse is small, weak, and quick.
On auscultation both the sounds may be free from murmur. Often
there is the condition known as embryocardia or foital heart-rhythm, in
which the first and second sounds are very alike, and the long pause is
shortened. In other instances there is the typical and characteristic
gallop rhythm, rarely found apart from conditions of dilatation. With
the various valvular lesions the corresponding murmurs may be heard.
Murmurs, however, which have been present may disappear, as in the case
of mitral stenosis. In other instances a loud systolic murmur may be
heard at the apex, and when the case first comes under observation it
may be impossible to say whether this is due to organic mitral lesion.
The murmur may be confined to the apex region, or propagated well to
the back. It is extremely common in the dilatation which follows the
hypertrophy of the left ventricle in arterio-sclerosis. Under treatment,
with the gradual disappearance of the dilatation, a murmur of this kind,
even though most intense, may completely disappear, showing that it has
been due to a relative insufficiency, not to a valvular lesion. All varieties
of arrhythmia may occur in dilatation of the heart. The pulse, as a rule,
is small, weak, quick, and often irregular.
Dilatation and Hypertrophy due to Overexertion and Alcohol. — There
is a group of cases of dilatation and h3rpertrophy dependent upon pro-
longed overexertion, which rarely comes under observation until compen-
sation has failed, and which then may be very difficult to distinguish from
the similar conditions produced by valvular disease. The patients are
able-bodied men at the middle period of life, and complain first of pal-
pitation or irregularity of the action of the heart, shortness of breath, and
subsequently the usual symptoms of cardiac insufficiency develop. On
inquiring into the history of these patients none of the usual etiological
factors causing valve disease are present, but they have always been en-
gaged in laborious occupations and have usually been in the habit of
taking stimulants freely. This is the affection which has been specially
studied by McLean, Clifford Albutt, Seitz, and others, and in its earlier
condition by Da Costa, in what he termed the irritable heart It is met
with very frequently in soldiers. These cases may return to hospital
three or four times with cardiac insufficiency, sometimes with slight ana-
sarca, haemoptysis, and signs of pulmonary engorgement. The condition
is by no means infrequent. Bollinger has called attention to the common
occurrence of dilatation and hypertrophy in beer-drinkers, particularly in
the workers in the German breweries, who drink twenty or more litres in
the day. Striimpell, at his Erlangen clinic, told me that this condition
was very common in the draymen and workers in the breweries of that
town, very few of whom pass the forty-fifth year without indications of
hypertrophy and dilatation of the heart. On post-mortem examination the
valves may be quite healthy, the aorta smooth, and no extensive arterio-
6J:0 DISEASES OF THE CIRCULATORY SYSTEM.
sclerosis or renal disease. The heart weighs from eighteen to twenty-five
ounces ; the chambers are dilated. The condition has been met with also
in animals, and Houghton states that the heart of the celebrated grey-
hound Master McGrath weighed 9*57 ounces, just threefold in excess of
the normal proportion of heart-weight to body- weight.
Idiopathic Dilatation. — And, lastly, there are other cases in which
dilatation of the heart occurs without discoverable cause. In some in-
stances there has been a history of sudden exercise or of mental emotion,
but in other cases the condition seems to have come on spontaneously.
In some the condition is acute and the patient has dyspnoea, slight cyano-
sis, cough, and great cardiac distress. Death may occur in a few days, or
dropsy may supervene and the case may become chronic. Delafield has
reported an interesting series of cases of this group.
Treatment. — The treatment of hjrpertrophy and dilatation has al-
ready been considered under the section on valvular lesions. I would
only here emphasize the fact that with signs of dilatation, as indicated by
gallop rhythm, urgent dyspnoea, and slight lividity, venesection is in
many cases the only means by which the life of the patient may be saved,
and from twenty-five to thirty ounces of blood should be abstracted with-
out delay. Subsequently stimulants, such as ammonia and digitalis, may
be administered, but they are accessories only to the bleeding in the criti-
cal condition of acute dilatation, which is so frequently met with in
cardiac lesions.
IV. AFFECTIONS OF THE MYOCARDIUM.
1. Lesions due to Disease of the Coronary Arteries. — A knowledge of the
changes produced in the myocardium by disease of the coronary vessels
gives a key to the understanding of many problems in cardiac pathol-
ogy. The terminal branches of the coronary vessels are end arteries.
The blocking of one of these vessels by a thrombus or an embolus leads to
a condition which is known as —
(a) Ancemic necrosis^ or white infarct. This is most commonly seen
in the left ventricle and in the septum, in the territory of distribution
of the anterior coronary artery. The affected area has a yellowish-
white color, sometimes a turbid, parboiled aspect, at others a grayish-
red tint. It may be somewhat wedge-shaped, more often it is irregular
in contour and projects above tlie surface. • Microscoi)ically the changes
are very characteristic. The nuclei disappear from the muscle fibres,
the condition of fragmentation is present, and the fibres present a ho-
mogeneous, hyaline appearance. In some instances there is complete
transformation, and even to the naked eye a firm white patch of hyaline
degeneration may appear in the centre of the area. Sudden death not
infrequently follows the blocking of one of the branches of the coronary
AFFECTIONS OF THE MYOCARDIUM. 641
artery and tlie production of this anaemic necrosis. In medico-legal
cases it is a point of primary importance to rememher that this is one
of the comtnon causes of sudden death. This condition should be care-
fully sought for, inasmuch as it may be the sole lesion, except a general,
sometimes slight arterio-sclerosis. Rupture of the heart may be asso-
ciated with anaemic necrosis.
(b) The second important effect of coronary-artery disease upon the
myocardium is seen in the production of fibrous myocarditis. This may
result from the gradual transformation of areas of angemic necrosis.
More commonly it is caused by the narrowing of a coronary branch in
a process of obliterative endarteritis. The sclerosis is most frequently
seen at the apex of the left ventricle and in the septum, but it may
occur in any portion. In the septum often there are streaks of fibroid
degeneration which do not reach the endocardium, and it may be neces-
sary to divide the muscle in order to see them. Hypertrophy of the heart
is commonly associated with this degeneration. It is the invariable pre-
cursor of aneurism of the heart.
Complete obliteration of one coronary artery, if produced suddenly, is
usually fatal. When induced slowly, either by arterio-sclerosis at the ori-
fice of the artery at the root of the aorta or by an obliterating endarteritis
in the course of the vessel, the circulation may be carried on through the
other vessel. Sudden death is not uncommon, owing to thrombosis of a
vessel which has become narrowed by sclerosis. In the most extreme
grade one coronary artery may be entirely blocked, with the produc-
tion of extensive fibroid disease, and a main branch of the other also
may be occluded. A large, powerfully built imbecile, aged thirty-five, at
the Elwyn Institution, Pennsylvania, who had for years enjoyed doing the
heavy work about the place, died suddenly, without any preliminary symp-
toms. The heart, which is in my collection, weighed over twenty ounces ;
the anterior coronary artery was practically occluded by obliterating en-
darteritis, and of the posterior artery one main branch was occluded.
(c) Septic hifarcts. — In pyaemia the smaller branches of the coronary
arteries may be blocked with septic emboli and cause infarcts in the myo-
cardium in the form of miliary abscesses, varying in size from a pea to
a pin's head. These may not cause any disturbance, but when large they
may perforate into the ventricle or into the pericardium, forming what
has been called acute ulcer of the heart.
2. Acute Interstitial Myocarditis. — In the fevers and in pericarditis
the intermuscular connective tissue is swollen and infiltrated with round
cells and nuclei, the vessels are dilated, there are minute extravasations,
and the muscle fibres may be granular or fatty, with indistinct striae and
nuclei. These instances have been met with in typhoid fever, small-
pox, and diphtlieria. The muscle substance is pale, soft, and easily torn,
and the condition has been described either as inflammatory or degener-
ative.
C42 DISEASES OF THE CIRCULATORY SYSTEM.
3. Parenchymatous Degeneration. — This is usually met with in fevers,
or in connection with endocarditis or pericarditis. It is characterized
by a pale, turbid state of the cardiac muscle, which is general, not local-
ized. Turbidity and softness are the special features. It is the soft-
ened heart of Laennec and Louis. Stokes speaks of an instance in which
" so great was the softening of the organ that when the heart was grasped
by the great vessels and held with the apex pointing upward, it fell down
over the hand, covering it like a cap of a large mushroom."
Histologically, there is a degeneration of the muscle fibres, which are
infiltrated to a various extent with granules which resist the action of
ether. Sometimes this granular change in the fibres is extreme, and no
trace of the striae can be detected. It is probably the effect of a toxic
agent, and is seen in its most exquisite form in the lumbar muscles in
cases of toxic haemoglobinuria in the horse. It is met with in cases of
typhoid, typhus, small-pox, and other infectious diseases, particularly when
the course is protracted. There is no definite relation between it and the
high temperature.
A form of myocarditis has been described, characterized by fragmenta-
tion of the fibres owing to softening of the cement substance. According
to von Recklinghausen this is a post-mortem change.
4. Fatty Heart. — Under this term are embraced fatty degeneration
and fatty overgrowth.
(a) Fatty degeneratio7i is a very common condition, and mild grades
are met with in many diseases. It is found in the failing nutrition of
old age, of wasting diseases, and of cachectic states ; in prolonged infec-
tious fevers, in which it may follow or accompany the parenchymatous
change ; associated with acute and chronic anaemias. Certain poisons, such
as phosphorus, produce an intense fatty degeneration. Local causes : Peri-
carditis is usually associated with fatty or parenchymatous changes in the
superficial layers of the myocardium. Disease of the coronary arteries is
a common and important cause. Lastly, in the hypertrophied ventricular
wall in chronic heart-disease fatty change is by no means infrequent.
This degeneration may be limited to the heart or it may be more or less
general in the solid viscera. The diaphragm may also be involved, even
when the other muscles show no special changes. There appears to be
a special pr oneness to fatty degeneration in the heart-muscle, which may
perhaps be connected with its incessant activity. So great is its need of
an abundant oxygen supply that it feels at once any deficiency, and is in
consequence "the first muscle to show nutritional changes.
Anatomically the condition may be local or general. The left ven-
tricle is most frequently affected. If the process is advanced and general
the heart looks large and is flabby and relaxed. It has a light yellowish-
brown tint, or, as it is called, a faded-leaf color. Its consistence is re-
duced and tlie substance tears easily. In the left ventricle the papillary
columns and the muscle beneath the endocardium show a streaked or
AFFECTIONS OF THE MYOCARDIUM. 643
patchy appearance. Microscopically, the fibres are seen to be occupied by
minute globules distributed in rows along the line of the primitive fibres
(Welch). In advanced grades the fibres seem completely occupied by the
minute globules.
(b) Fatty Overgroicth. — This is usually a simple excess of the normal
subpericardial fat, to which the term cor adiposum was given by the
older writers. In other instances the fat infiltrates the muscular sub-
stance and, separating the strands, may reach even to the endocardium.
In corpulent persons there is always much pericardial fat. It forms part
of the general obesity, and occasionally leads to dangerous or even fatal
impairment of the contractile power of the heart. Of 122 cases analyzed
by Forchheimer there were 88 males and 3-4 females. Over eighty per
cent occurred between the fortieth and seventieth years.
The entire heart may be enveloped in a thick sheeting of fat through
which not a trace of muscle substance can be seen. On section, the fat
infiltrates the muscle, separating the fibres, and in extreme cases — particu-
larly in the right ventricle — reaches the endocardium. In some places there
may be even complete substitution of fat for the muscle substance. In
rare instances the fat may be in the papillary muscles. The heart is usual-
ly much relaxed and the chambers are dilated. Microscopically the mus-
cle fibres may show, in addition to the atroph}^ marked fatty degeneration.
5. Other Degenerations of the Myocardium, (a) Broicm Atrophy. —
This is a common change in the heart-muscle, particularly in chronic
valvular lesions and in the senile heart. When advanced, the color of the
muscles is a dark red-brown, and the consistence is usually increased.
The fibres present an accumulation of yellow-brown pigment chiefly
about the nuclei. The cement substance is often unusually distinct, but
seems more fragile than in healthy muscle.
{b) Amyloid degeneration of the heart is occasionally seen. It occurs
in the intermuscular connective tissue and in the blood-vessels, not in
the fibres.
(6') The hyaline transformation of Zenker is sometimes met with in
prolonged fevers. The affected fibres are swollen, homogeneous, trans-
lucent, and the striae are very faint or entirely absent.
{(1) Calcareous degeneration may occur in the myocardium, and the
muscle fibres may be infiltrated and yet retain their appearance as figured
and described by Coats in his Text-book of Pathology.
Symptoms of Myocardial Disease. —These are notoriously un-
certain. A man with advanced fibroid myocarditis may drop dead sud-
denly, while doing heavy work, Avithout having complained of cardiac dis-
tress. On the other hand, a patient may present enfeebled, irregular action
and signs of dilatation ; he may have shortness of breath, a»dema, and the
general symptoms believed to be characteristic of cases of fibroid and fatty
heart, and the post-mortem show little or no change in the myocardium.
Cardio-sclerosis or fibroid heart is in some cases characterized by a
0-t4: DISEASES OF THE CIRCULATORY SYSTEM.
feeble, irregular, slow pulse, with dyspnoea on exertion and occasional at-
tacks of angina. Irregularity is present in many, but not in all cases.
The pulse may be very slow, even 30 or 40 per minute. Ultimately the
cases come under observation with the symptoms of cardiac insufficiency.
The arrhytlimia, which may have been present, becomes aggravated and,
according to Riegel, may not only precede, but also persist after the car-
diac insufficiency has passed away. This certainly does not hold in all
cases, for a patient recently under observation had the most marked ar-
rhythmia, which persisted after recovery from a severe attack of cardiac
insufficiency in which he nearly died. Upon his return, a few weeks ago,
with dilatation and arrhythmia, we agreed that the condition was prob-
ably one of cardio-sclerosis ; but the autopsy showed simple dilatation
without either fibroid or marked fatty change in the heart.
Fatty degeneration of the heart presents the same difficulties. Extreme
fatty changes, as in pernicious anaemia, may be consistent with full, regu-
lar pulse and a regularly acting heart. In some of these cases the fat does
not appear to interfere seriously with the function of the organ. The truth
is it may exist in an extreme grade without producing symptoms, so long as
great dilatation of the chambers does not occur. The cardiac irregularity,
the dyspnoea, palpitation, and small pulse are in reality not symptoms of
the fatty degeneration, but of dilatation which has supervened. The fatty
arciis senilis is of no moment in the diagnosis of fatty heart. The heart-
sounds may be weak and the action irregular. When dilatation occurs,
there is often the gallop rhythm, shortening of the long pause, and a sys-
tolic murmur at the apex. Shortness of breath on exertion is an early
feature in many cases, and anginal attacks may occur. There is some-
times a tendency to syncope, and in both fibroid and fatty heart there are
attacks in which the patient feels cold and depressed and the pulse sinks
to 40 or 30, or even, as in one case which I saw, to 26. The patient may
wake from sleep in the early morning with an attack of severe cardiac
asthma. These " spells " may be associated with nausea and may alter-
nate with others in which there are anginal symptoms. These are the
cases, too, in which for weeks there may be mental symptoms. The pa-
tient has delusions and may even become maniacal. Toward the close,
Cheyne-Stokes breathing is met with in a number of cases.
Fatty overgrowth of the heart is a condition certain to exist in very
obese persons. It produces no symptoms until the muscular fibre is so
weakened that dilatation occurs. These patients may for years present a
feeble but regular pulse ; the heart-sounds are weak and muffled, and a
murmur may be heard at the apex. Attacks of cardiac asthma are not
uncommon, and the patient may suffer from bronchitis. Dizziness and
pseudo-apoplectic seizures may occur. Sudden death may result from
syncope or from rupture of the heart. The physical examination is often
difticult because of the great increase in the fat, and it may be impossible
to define the area of dulness.
AFFECTIONS OF THE MYOCARDIUM. 615
For practical purposes wc may group the cases of myocardial disease
as follows :
(1) Those in which sudden death occurs with or without previous in-
dications of heart-trouble. Sclerosis of the coronary arteries exists — in
some instances with recent thrombus and white infarcts ; in others, exten-
sive fibroid disease ; in others again, fatty degeneration. In many cases
there is never any complaint of cardiac distress, but, as in the case of
Chalmers, the celebrated Scottish divine, may enjoy unusual vigor of mind
and body.
(2) Cases in which there are cardiac arrhythmia, shortness of breath
on exertion, attacks of cardiac asthma, sometimes anginal attacks, collapse
symptoms with sweats and extremely slow pulse, and occasionally marked
mental symptoms. These are the cases in which the condition may be
strongly suspected and, in some instances, diagnosed. It is rarely possible
to make a distinction between the fatty and fibroid heart.
(3) Cases in which there are cardiac insufficiency and symptoms of dila-
tation of the heart. Dropsy is often present, and with a loud murmur at
the apex it may be difficult, unless the case has been seen from the outset,
to determine whether or not a valvular lesion is present.
Prognosis. — The outlook in affections of the myocardium is ex-
tremely grave. Patients recover, however, in a surprising way from the
most serious attacks, particularly those of the second group.
Treatment. — Many cases never come under treatment ; the first are
the final symptoms.
Cases with signs of well-marked cardiac insufficiency, as manifested by
dyspnoea, weak, irregular, rapid heart, and oedema, may be treated on the
plan laid down for the treatment of broken compensation in valvular dis-
ease. Digitalis may be given even if fatty degeneration is suspected, and
is often very beneficial.
Much more difficult is the management of those cases in which there
is marked cardiac arrhythmia, with a feeble, irregular, very slow pulse,
and syncope or angina. Dropsy is not, as a rule, present ; the heart-
sounds may be perfectly clear, and there are no signs of dilatation. Di-
gitalis, under these circumstances, is not advisable, particularly when the
pulse is infrequent. Complete rest in bed, a carefully regulated diet, and
the use of the aromatic spirits of ammonia, sulphuric ether, and stimulants
are indicated. For the restlessness and distressing feelings of anxiety mor-
phia is invaluable. From an eightieth to a sixtieth of a grain of strychnia
may be given three times a day. If, as is sometimes the case, the pulse is
hard and firm, nitroglycerin may be cautiously administered, beginning
with one minim of the one per cent solution tliree times a day and in-
creased gradually.
In certain cases of weak heart, particularly when it is due to fatty over-
growth, the plan of treatment recommended by Oertl is advantageous. It
is an invaluable method in those forms of heart- weakness due to intern-
Q4:6 DISEASES OF THE CIRCULATORY SYSTEM.
perance in eating and drinking and defective bodily exercise. The Oertl
plan consists of three parts. First, the reduction in the amount of liquid.
This is an important factor in reducing the fat in these patients. It also
slightly increases the density of the blood. Oertl allows daily about thirty-
six ounces of liquid, which includes the amount taken with the solid food.
Free perspiration is promoted by bathing (if advisable, the Turkish bath),
or even by the use of pilocarpine.
The second important point in his treatment is the diet, which should
consist largely of proteids.
Morning. — Cup of coffee or tea, with a little milk, about six ounces
altogether. Bread, three ounces.
Noon. — Three to four ounces of soup, seven to eight ounces of roast
beef, veal, game, or poultry, salad or a light vegetable, a little fish ; one
ounce of bread or farinaceous pudding ; three to six ounces of fruit for
dessert. No liquids at this meal, as a rule, but in hot weather six ounces
of light wine may be taken.
Afternoon. — Six ounces of coffee or tea, with as much water. As an
indulgence an ounce of bread.
Evening. — One or two soft-boiled eggs, an ounce of bread, perhaps a
small slice of cheese, salad, and fruit ; six to eight ounces of wine with four
or five ounces of water (Yeo).
The most important element of all is graduated exercise, not on the
level, but up hills of various grades. The distance walked each day is
marked off and is gradually lengthened. In this way the heart is sys-
tematically exercised and strengthened.
There is no doubt of the great value of this or like methods in appro-
priate cases. At several of the health resorts in Germany, particularly
the Bad Nauheim, under Schott, the results are striking. The plan is
rarely advisable in valvular lesions and should not be adopted when there
is marked arterio-sclerosis. Cases of fatty overgrowth of the heart are
those most suitable. The plan of treatment reduces the obesity, and the
patients are, for a time at least, much more comfortable and are able to go
about and do their work without cardiac distress or great shortness of
breath.
Aneurism of the Heart.
(«) Aneurism of a Valve results from acute endocarditis, which pro-
duces softening or erosion and may lead either to perforation of the seg-
ment or to gradual dilatation of a limited area under the influence of the
blood-pressure. The aneurisms are usually spheroidal and project from
the ventricular face of a sigmoid valve. They are much less common
on the mitral segments. They frequently rupture and produce extensive
destruction and incompetency of the valves.
(h) Aneurism of the Walls. — This comparatively rare condition results
from tlie weakening of the walls by chronic myocarditis, or occasionally
AFFECTIONS OF THE MYOCARDIUM. 047
it follows mural endocarditis, which more commonly, however, leads to
perforation. Aneurism has followed a stab-wound of the heart. The
left ventricle near the apex is usually the seat, at the situation in
which the fibrous degeneration is most common. Fifty-nine of the 90
cases collected by Legg were situated here. In the early stages the ante-
rior wall of the ventricle, near the septum, sometimes involving the septum
itself, is slightly dilated, the endocardium opaque, and the muscular tissue
sclerotic. In a more advanced stage the dilatation is pronounced and
layers of thrombi occupy the sac. Ultimately a large rounded tumor may
project from the ventricle and may attain a size equal to that of the heart.
Occasionally the aneurism is sacculated and communicates with the ven-
tricle through a very small orifice. The sac may be double, as in a case
reported by Janeway. In the museum of Guy's Hospital there is a speci-
men showing the wall of the ventricle covered with aneurismal bulgings.
Kupture occurred in 7 of the 90 cases collected by Legg.
The symptoms produced by aneurism of the heart are indefinite. Oc-
casionally there is marked bulging in the apex region and the tumor may
perforate the chest wall. When the sac is large and produces pressure
upon the heart itself, there may be a marked disproportion between the
strong cardiac impulse and the feeble pulsation in the peripheral arteries.
Rupture of the Heart.
This rare event is usually associated with fatty infiltration or degenera-
tion of the heart-muscles. In some instances, acute softening in conse-
quence of embolism of a branch of the coronary artery, suppurative myo-
carditis, or a gummatous growth has been the cause. Of 100 cases col-
lected by Quain, fatty degeneration was noted in 77. Two thirds of the
patients were over sixty years of age.
The rent may occur in any of the chambers, but is found most fre-
quently in the left ventricle on the anterior wall, not far from the septum.
The accident usually takes place during exertion. There may be no pre-
liminary symptoms, but without any warning the i)atient may fall and die
in a few moments. Sudden death occurred in seventy-one per cent of
Quain's cases. In other instances there may be in the cardiac region a
sense of anguish and suffocation, and life may be prolonged for several
hours. In a Montreal case which I examined the patient walked up a
steep hill after the onset of the symptoms, and lived for thirteen hours.
A case is on record in which the patient lived for eleven days.
New Growths and Parasites.
Tubercle and syphilis have already been considered. Primary cancer
or sarcoma is extremely rare. Secondary tumors may be single or mul-
tiple, and are usually unattended with symptoms, even when the disease
648 DISEASES OF THE CIRCULATORY SYSTEM.
is most extensive. In one case I found in the wall of the right ventricle
a mass which involved the anterior segment of the tricuspid valve and
partly blocked the orifice. The surface was eroded and there were nu-
merous cancerous emboli in the pulmonary artery. In another instance
the heart was greatly enlarged, owing to the presence of innumerable
masses of colloid cancer the size of cherries. The mediastinal sarcoma
may penetrate the heart, though it is remarkable how extensive the dis-
ease of the mediastinal glands may be without involvement of the heart
or vessels.
Cysts in the heart are rare. They are found in different parts, and
are filled either with a brownish or a clear fluid. Blood-cysts occasionally
occur.
The parasites will be discussed under the appropriate section, but it
may be mentioned here that both the cysticermis celluloscB and the echino-
coccus cysts occur occasionally in the heart.
Wounds and Foreign Bodies.
Wounds of the heart are usually fatal, although there are many in-
stances in which recovery has taken place. Bullets have been found en-
cysted inside the ventricle. A majority of the cases of gunshot wounds,
however, are necessarily fatal. Puncture of the heart by a sharp-point-
ed body, such as a needle or a stiletto, does not always prove fatal.
Peabody has reported a case in which a pin was found embedded in the
left ventricle. Suicide has been attempted by passing a needle or pin
into the heart. It is not, however^ necessarily fatal. Moxon mentioned a
case, at the Clinical Society of London, in which a medical student, while
on a spree, passed a pin into his heart. The pericardium was opened, and
the head of the pin was found outside of the right ventricle. It was
grasped and an attempt made to remove it, but it was withdrawn into the
heart and, it is said, caused the patient no further trouble. Hysterical
girls sometimes swallow pins and needles, which, passing through the
oesophagus and stomach, are found in various parts of the body. A re-
markable case is reported by Allen J. Smith of a girl from whom several
dozen needles and pins were removed, usually from subcutaneous abscesses.
Several years later she developed symptoms of chronic heart-disease. At
the post-mortem needles were found in the tissues of the adherent peri-
cardium, and between thirty and forty were embedded in the thickened
pleural membranes of the left side.
Puncture of the heart has been recommended as a therapeutic pro-
cedure to stimulate it to action, as in chloroform narcosis, and experi-
mental evidence has been brought forward by B. A. Watson in favor of
the operation. He advises abstraction of blood in combination with the
puncture — cardiocentesis. The proceeding is not without risk. Haemor-
rhage may take place from the puncture, though it is not often extensive.
NEUROSES OF THE HEART. 649
At the Philadelpliia Hospital tlie procedure was tried by one of the resi-
dent physicians in a case of acute dilatation. The anterior coronary yein
was cut across and considerable blood was found in the pericardium.
There is danger also of striking Kronecker's inhibition centre.
V. NEUROSES OF THE HEART.
Palpitation^.
In health we are unconscious of the action of the heart. In some peo-
ple one of the first indications of debility or overwork is the consciousness
of the cardiac pulsations, which may, however, be perfectly regular and
orderly. This is not palpitation. The term is properly limited to irregu-
lar or forcible action of the heart perceptible to the individual.
Etiology. — The expression "perceptible to the individual" covers
the essential element in palpitation of the heart. The most extreme dis-
turbance of rhythm, a condition even of what is termed delirium cordis^
may be unattended with subjective sensations of distress, and there may
be no consciousness of disturbed action. On the other hand, there are
cases in which complaint is made of the most distressing palpitation and
sensations of throbbing, in which the physical examination reveals a regu-
larly acting heart, the sensations being entirely subjective. AVe meet with
this symptom in a large group of cases in which there is increased excita-
bility of the nervous system. Palpitation may be a marked feature at the
time of puberty, at the climacteric, and occasionally during menstruation.
It is a very common symptom in hysteria and neurasthenia, particularly in
the form of the latter which is associated with dyspepsia. Emotions,
such as fright, are common causes of palpitation. It may occur as a
sequence of the acute fevers. Females are more liable to the affection than
males.
In a second group the palpitation results from the action upon the
heart of certain substances, such as tobacco, coffee, tea, and alcohol. And,
lastly, palpitation may be associated with organic disease of the heart,
either of the myocardium or of the valves. As a rule, however, it is a
purely nervous phenomenon — seldom associated with organic disease — in
which the most violent action and the most extreme irregularity may exist
without that subjective element of consciousness of the disturbance which
constitutes the essential feature of palpitation.
The irritable heart described by Da Costa, which was so common among
the young soldiers during the civil war, is a neurosis of this kind. The
chief symptoms were palpitation with great frequency of the pulse on ex-
ertion, a variable amount of cardiac pain, and dyspna3a. The factors at
work in producing this condition appeared to be the mental excitement,
the unwonted muscular exertion associated with the drill, and diarrhoea.
(^50 DISEASES OF THE CIRCULATORY SYSTEM.
The condition is not infrequent in civil life among young men, and it leads
in some cases to h3rpertrophy of the heart.
Sjrmptonis. — In the mildest form, such as occurs during a dys-
peptic attack, there is slight fluttering of the heart and a sense of what
patients sometimes call "goneness." In more severe attacks the heart
beats violently, its pulsations against the chest wall are visible, the rapidity
of the action is much increased, the arteries throb forcibly, and there is a
sense of great distress. In some instances the heart's action is not at all
quickened. The most striking cases are in neurasthenic women, in whom
the mere entrance of a person into the room will cause the most violent
action of the heart and throbbing of the peripheral arteries. The pulse
may be rapidly increased until it reaches 150 or 160. A diffuse flushing
of the skin may appear at the same time. After such attacks, there may
be the passage of a large quantity of pale urine. In many cases of palpi-
tation, particularly in young men, the condition is at once relieved by
exertion. A patient with extreme irregularity of the heart may, after
walking quickly one hundred yards or running up-stairs, return with the
pulse perfectly regular. This is not infrequently seen, too, in the irregu-
lar action of the heart in mitral-valve disease.
The physical examination of the heart is usually negative. The sounds,
the shock of which may be very palpable, are on auscultation clear, ringing,
and metallic, but not associated with murmurs. The second sound at the
base may be greatly accentuated. A murmur may sometimes be heard
over the pulmonary artery or even at the apex in cases of rapid action in
neurasthenia or in severe anaemia. The attacks may be transient, lasting
only for a few minutes, or may persist for an hour or more. In some in-
stances any attempt at exertion renews the attack.
The prognosis is usually good, though it may be extremely difficult to
remove the conditions underlying the palpitation.
Arrhythmia.
An intermission occurs when one or more beats of the heart are
dropped. Irregularity is the condition when the beats are unequal in vol-
ume and force, or follow each other at unequal distances. Allorrhythmia
is a term which is also used to express deviations from the normal heart
rhythm.
The following varieties of arrhythmical action may be recognized :
(1) The paradoxical pulse of Kiissmaul, in which the beats during
inspiration are more frequent but less full than during expiration. This
is found in weak heart, in chronic pericarditis, and when fibrous bands
encircle the root of the aorta ; but it may also occur normally from the
influence of the respirations upon the heart. It is sometimes to be felt in
sleeping children.
(2) Intermittence, in which there is simply an intermission or drop-
NEUROSES OF THE HEART. 651
ping of a cardiac beat. The term .dcficiencc is more correctly applied to
those instances in which the absence of the heart-sound proves that the
systole is really omitted. The systole may be so weak as not to produce a
pulsation, and yet at the same time a feeble first sound may be heard.
(3) The alternate heart-beat, in which strong and weak pulsations
alternate regularly and which is expressed in the peripheral arteries by
alternate full and feeble pulse-beats.
(4) The bigeminal and trigeminal pulsations occur when two or three
beats follow each other in rapid succession, each group being separated
from the following by a longer interval. This is not very uncommon in
mitral disease. In the bigeminal pulse the first beat of the pair is usually
the stronger. Indeed, in the condition known as heart bigeminism the
second systole is so feeble that the pulse wave does not reach the periph-
eral arteries and the two systoles are represented by only a single pulse-
beat at the wTist.
(5) Delirium cordis, in which these various factors are combined and
the heart's action is wholly irregular.
(6) Foetal heart rhythm — embryocardia — described by Stokes, is a
very common condition in which the long pause is shortened and the
characters of the sounds are " almost completely identical." The resem-
blance to the foetal heart-beat is very striking. In the later stages of
fevers and in extreme dilatation this form of heart rhythm is very fre-
quently heard.
(7) Gallop rhythm, in which the sounds resemble the footfall of a
horse at canter, usually results from the reduplication of the second
sound in a rapidly acting heart. It is expressed by the words "■ rat-
ta-tat." Sometimes it seems as if the first sound was split ; more com-
monly it is the second. It is most frequently heard in interstitial ne-
phritis and arterio-sclerosis, but it is said to be met with also in healthy
persons.
The causes of these various disturbances of rhythm are thus classified
by G. Baumgarten : *
(1) Those due to central — cerebral — causes, either organic disease, as
in haemorrhage, or concussion ; more commonly psychical influences.
(2) Reflex influences, such as produce the cardiac irregularity in dys-
pepsia and diseases of the liver, lungs, and kidneys.
(3) Toxic influences. Tobacco, coffee, and tea are common causes of
arrhythmia. Various drugs, such as digitalis, belladonna, and aconite,
may also induce it.
(4) Ghanges in the heart itself, (a) In the cardiac ganglia. Fatty,
pigmentary, and sclerotic changes have been described in cases of this
sort and may have an important influence in producing disturbances in
the rhythm ; but as yet we do not know their exact significance. They
* Transactions of the Association of American Physicians, vol, iii.
42
652 DISEASES OP THE CIRCULATORY SYSTEM.
may be present in cases which have not presented arrhythmia, (h) Mural
changes are common in conditions of this kind. Simple dilatation, fatty
degeneration, and sclerosis are most commonly present, the two latter
usually associated with sclerosis of the coronary arteries.
The significance of arrhythmia is not always easy to determine. Sim-
ple irregular action of tlie heart may persist for years. The late Chan-
cellor Terrier, of McGill University, a man of unusual bodily and mental
vigor, who died at the age of eighty-seven, had an extremely irregular
pulse for almost fifty years of his life. One or two other instances have
come under my notice of persons in good health, without arterial or car-
diac disease, in whom the heart's action was persistently irregular. The
bigeminal and trigeminal pulsations are found more frequently in mitral
than in other conditions. The delirium cordis is met with in the dilata-
tion associated with valvular lesions, particularly toward the latter stages.
Foetal heart rhythm is rarely found apart from dilatation.
Rapid Heart — Tachycardia.
The rapid action may be perfectly natural. There are individuals
whose normal heart action is at 100 or even more per minute. It may
be caused by the various conditions which induce palpitation ; but the
two are not necessarily associated. Emotional causes, violent exercise, and
fevers all produce great increase in the rapidity of the heart's action.
The extremely raj)id action which follows fright may persist for days, or
even weeks. Traube reports an instance in which, after violent exercise,
the rapid action of the heart continued. Cases are not uncommon at the
menopause.
There are cases again in which the condition can hardly be termed a
neurosis, since it depends upon definite changes in the pneumogastrics
or in the medulla. Cases have been reported in which tumor or clot in
or about the medulla or pressure upon the vagi has been associated with
heart hurry. Some of the cases of frequent action of the heart in women
have been thought to be due to reflex irritation from ovarian or uterine
disease.
Paroxysmal tachycardia is a remarkable affection, characterized by
spells of heart hurry, during which the action is greatly increased, the
pulse reaching 200 and over. The cases are not common. The condition
has been tlioroughly studied by Nothnagel. The attack may be quite
short and persist only for an hour or so. A patient at the Pliiladelpliia
Infirmary for Nervous Diseases was attacked every week or two ; the pulse
woukl rise to 220 or 230, and there were such feelings of distress and un-
easiness that the patient always had to lie down. There may be, however,
no subjective disturbance, and in- another case the patient was able to
walk about during the paroxysm and had no dyspnoea. One of the most
remarkable cases is reported by II. C. Wood. A physician in his eighty-
NEUROSES OF THE HEART. G53
seventh year has had attacks at intervals since liis thirty-seventh year.
The onset is abrupt and the pulse rapidly rises to 200 a minute. For more
than twenty years the taking of ice-water or strong coffee would arrest the
attacks. Bouveret has analyzed a number of cases of this essential or
idiopathic form ; he finds that a permanent cure is rare, and that the pa-
tients suffer for ten or more years. Four instances terminated fatally from
heart-failure. Wood suggests that these cardiac paroxysms are caused
by discharging lesions affecting the centres of the accelerator nerves.
Fran9ois Franck has shown that the acceleration of the heart's action is
due to the shortening of the diastole, and during the systole so little blood
is expelled from the heart that the average amount in the minute is not
increased. Moreover, the accelerators appear to have no trophic relation
to the heart, and stimulation of them is not accompanied either by in-
creased arterial pressure or by augmentation of the work done by the
heart.
Slow Heart — Brachycardia {Bradycardia).
Slow action of the heart is sometimes normal and may be a family
peculiarity. Napoleon is stated to have had a pulse of only 40 per minute.
In any case of slow pulse it is important first to make sure that the
number of heart, and arterial beats correspond. In many instances this is
not the case, and with a radial pulse at 40 the cardiac pulsations may be
80, half the beats not reaching the wrist. The heart contractions, not the
pulse wave, should be taken into account. A most exhaustive study of
this condition has been made recently by Riegel, whose division is here
followed :
(a) Physiological brachycardia. In the puerperal state the pulse may
beat from 44 to 60 per minute, or may even be as low as 34. It is seen in
premature labor as well as at term. The explanation of its occurrence at
this period is not clear. Slowness of the pulse is associated with hunger.
Brachycardia depending on individual peculiarity is extremely rare.
{h) Pathological brachycardia, which is met with under the following
conditions : (1) In convalescence from acute fevers. This is extremely
common, particularly after pneumonia, typhoid fever, acute rheumatism,
and diphtheria. It is most frequently seen in young persons and in cases
which have run a normal course. Traube's explanation that it is due to
exhaustion is probably the correct one. (2) In diseases of the digestive
system, such as chronic dyspepsia, ulcer or cancer of the stomach, and
jaundice. The largest number of Riegel's cases were of this group. (3)
In diseases of the respiratory system. Here it is by no means so common,
but is seen not infrequently in emphysema. (4) In diseases of the circu-
latory system. Excluding all cases of irregularity of the heart, brachy-
cardia is not common in diseases of the valves. It is most frequently seen
in fatty and fibroid changes in the heart, but is not constant in them. (5)
In diseases of the urinary organs. It occurs occasionally in nephritis and
654: DISEASES OP THE CIRCULATORY SYSTEM.
may be a feature of uraemia. (G) From the action of toxic agents. It
occurs in uraemia, poisoning by lead, alcohol, and follows the use of to-
bacco, coffee, and digitalis. (7) In constitutional disorders, such as anae-
mia, chlorosis, and diabetes. (8) In diseases of the nervous system.
Apoplexy, epilepsy, the cerebral tumors, affections of the medulla, and
diseases and injuries of the cervical cord may be associated with very slow
puls^. In general paresis, mania, and melancholia it is not infrequent.
(9) It occurs occasionally in affections of the skin and sexual organs, and
in sunstroke, or in prolonged exhaustion from any cause.
It is seen most frequently in the convalescence from acute fevers, then
in disorders of the digestive system. The significance of this symptom is
variable. It is only in diseases of the heart or brain that it is ominous.
It may be due to direct irritation of the vagi, to diminished excitability of
the cardiac ganglia, to reflex influences acting upon the vagus centre, or
to weakness of the heart-muscle itself. The pulse-beat rarely sinks be-
low 20. Prentice, at the Association of American Physicians at Wash-
ington, showed a patient with attacks of unconsciousness, who had, par-
ticularly during the attacks, but also in the intervals, a pulse as low as
12 per minute. Such cases are extremely rare. Cases are on record in
which the pulse has fallen to 8 or 9 beats in the minute. At the dis-
cussion which followed the exhibition of Prentice's patient, both Jacobi
and Kinnicutt referred to similar cases associated with epileptic seizures,
in one of which the pulse fell as low as 7 in the minute.
Treatment of Palpitation and Arrhythmia. — An important
element in many cases is to get the patient's mind quieted, and he can be
assured that there is no actual danger. The mental element is ofte-ntimes
very strong. In palpitation, before using medicines, it is well to try the
effect of hygienic measures. As a rule, moderate exercise may be taken
with advantage. Kegular hours should be kept, and at least ten hours
out of the twenty-four should be spent in the recumbent posture. A tepid
bath may be taken in the morning, or, if the patient is weakly and nerv-
ous, in the evening, followed by a thorough rubbing. Hot baths and the
Turkish bath should be avoided. The dietetic management is most im-
portant. It is best to prohibit absolutely alcohol, tea, and coffee. The
diet should be light and the patient should avoid taking large meals.
Articles of food known to cause flatulency should not be used. If a
smoker, the patient should give up tobacco. Sexual excitement is par-
ticularly pernicious, and the patient should be warned specially on this
point. For the distressing attacks of palpitation which occur with neur-
asthenia, particularly in women, a rigid Weir-lMitchell course is the most
satisfactory. It is in these cases that we find the most distressing throb-
bing in the abdomen, which is apt to come on after meals, and is very
much aggravated by flatulency. The cases of palpitation due to excesses
or to errors in diet and dyspepsia are readily remedied by hygienic meas-
ures.
NEUROSES OF THE HEART. G55
A course of iron is often useful. Strychnia is particularly valuable,
and is perhaps best administered as the tincture of nux vomica in lar^e
doses. Very little good is obtained from the smaller quantities. It should
be given freely, 20 minims three times a day.
If there is great rapidity of action, aconite may be tried or veratrum
viride. There are cases associated with sleeplessness and restlessness which
are greatly benefited by bromide of potassium. Digitalis is very rarely
indicated, but in obstinate cases it may be tried with the nux vomica.
Cases of heart hurry are often extremely obstinate, as may be judged
from the case of the physician reported by H. C. Wood, in whom the con-
dition persisted in spite of all measures for fifty years. The bromides are
sometimes useful ; the general condition of neurasthenia should be treated,
and during the paroxysm an ice-bag may be placed upon the heart, or
Leiter's coil, through which ice-water may be passed. Electricity, in the
form of galvanism, is sometimes serviceable, and for its mental effect the
Franklinic current. For the condition of slow pulse but little can be
done. A great majority of the cases are not dangerous.
Akgina Pectoris.
Stenocardia, or the breast-pang described by Heberden, is not an inde-
pendent affection, but a symptom associated with a number of morbid
conditions of the heart and vessels, more particularly with sclerosis of
the root of the aorta and changes in the coronary arteries. True angina,
which is a rare disease, is characterized by paroxysms of agonizing pain
in the region of the heart, extending into the arms and neck. In violent
attacks there is a sensation of impending death.
Etiology and Pathology. — It is a disease of adult life and occurs
almost exclusively in men. Arterio-sclerosis, hypertrophy of the heart,
increased arterial tension, or aortic insufficiency are often present, while
anatomical changes in the aorta, arteries, and myocardium are almost
constant. No instance oi true angina has come under my observation in
which there were not signs of cardio-vascular changes. The immediate
exciting cause of an attack is most frequently sudden exertion or emo-
tional excitement. The paroxysm may come on in the daytime, but in
some of the worst cases they occur at night. The nature of the affection
is doubtful. The following views have been entertained.
(1) That it is a neuralgia of the cardiac nerves. In the true form the
agonizing cramp-like character of the pain, the suddenness of the onset,
and the associated features, are unlike any neuralgic affection. The pain,
however, is undoubtedly in the cardiac plexus and radiates to adjacent
nerves. It is interesting to note in connection with the almost constant
Hclorosis of the coronary arteries in angina that Thoma has found
marked sclerosis of the temporal artery in migraine and Dana has met
with local thickening of the arteries in some cases of neuralgia (2) Ileb-
656 DISEASES OF THE CIRCULATORY SYSTEM.
erden believed that it was a cramp of the heart-muscle itself. This
would explain the agonizing character of the pain and the suddenness of
the onset as well as the frequency of the fatal termination ; but if the
cramps were general in the heart-muscle and similar to those which occur
in the voluntary muscles, death would invariably ensue with great rapid-
ity. Cramp of certain muscular territories would explain the attack.
(3) That it is due to the extreme tension of the ventricular walls, in
consequence of an acute dilatation associated, in the majority of cases,
with affection of the coronary arteries. Traube, who supported this view,
held that the agonizing pain resulted from the great stretching and ten-
sion of the nerves in the muscular substance. A modified form of this
view is that there is a spasm of the coronary arteries with great increase
of the intracardiac pressure.
In fatal cases of angina the coronary arteries are almost invariably
diseased, either in their main division, or there is chronic endarteritis with
great narrowing of the orifices at the root of the aorta. Experimentally,
occlusion of the coronary arteries produces slowing of the heart's action,
gradual dilatation, and death within a very few minutes. Cohnheim has
shown that in the dog ligation of one of the large coronary branches pro-
duces within a minute a condition of arrhythmia, and within two minutes
the heart ceases in diastole. These experiments, however, do not throw
much light upon the etiology of angina pectoris. Extreme sclerosis of
the coronary arteries is common, and a large majority of the cases present
no symptoms of angina. Even in the cases of sudden death due to
blocking of an artery, particularly the anterior branch of the coronary
artery, there is usually no great pain either before or during the attack.
The lesions of the nerves described by Lancereaux, Hadden, and others
cannot yet be correlated satisfactorily with the symptoms of true angina.
Various forms of true angina have been recognized, but the differences, in
the majority of instances, are not sufficiently marked to permit a separa-
tion. Reference may be made, however, to the angina pectoris vaso-mo-
toria described by Nothnagel. In this the attack may come on after ex-
posure to cold. There is general spasm of the peripheral arteries with a
sense of stiffness and deadness in the extremities, and pallor, cyanosis, and
lowering of the temperature. The arteries are small and contracted.
There is sometimes a feeling of faintness or even a loss of consciousness.
With this there is a sense of pressure, tension, or even agonizing pain in
the cardiac region. The pulse, however, is regular, and there are no signs
of disease of the heart. The condition is supposed to depend upon a
wide-spread spasm of the peripheral arteries. I have never recognized a
case of this kind, although certain of its features are not at all uncommon
in the pseudo-angina.
Symptoms. — Usually during exertion or intense mental emotion the
patient is seized with an agonizing pain in the region of the heart and a
sense of constriction, as if the heart had been seized in a vise. The pains
NEUROSES OP THE HEART. 657
radiate up the neck and down the arm and there may be numbness of the
fingers or in the cardiac region. The face is usually pallid and may as-
sume an ashy-gray tint, and not infrequently a profuse sweat breaks
out over the surface. Dyspnoea is not usually present. The joaroxysm
lasts from several seconds to a minute or two, during which, in severe at-
tacks, the patient feels as if death were imminent. There is great rest-
lessness and anxiety, and the patient may drop dead at the height of the
attack or faint and pass away in syncope. The condition of the heart
during the attack is variable ; the pulsations may be uniform and regular.
The pulse tension, however, is usually increased, but it is surprising, even
in cases of extreme severity, how slightly the character of the pulse may
be altered. After the attack there may be eructations, or the passage of a
large quantity of clear urine. The patient usually feels exhausted, and
for a day or two may be badly shaken ; in other instances in an hour or
two the patient feels himself again. The attacks may recur at intervals
of a few weeks, or perhaps not for many years. There are individuals who
have well-marked anginal attacks for years, and, except during the par-
oxysms, suffer but slight inconvenience.
Diagnosis. — There are many grades of true angina. A man may
have slight prsecordial pain, a sense of distress and uneasiness, and radia-
tion of the pains to the arm and neck. Such attacks following slight ex-
ertion, an indiscretion in diet, or a disturbing emotion may alternate with
attacks of much greater severity, or they may occur in connection with
a pulse of increased tension and signs of general arterio-sclerosis. In the
milder grades the diagnosis cannot rest upon the symptoms of the attack
itself, since they may be simulated by the pseudo-angina ; but the diag-
nosis should be based upon the examination of the circulatory system.
In true angina, even in the milder forms, signs of arterio-sclerosis are
usually present. In a case presenting attacks of praecordial pain or pains
in the cervical or brachial plexuses, if the aortic second sound is clear, not
ringing, the pulse tension low, and the peripheral arteries soft, the diag-
nosis of true angina should not be made. After all, the chief difficulty,
however, arises in the cases of the hysterical or pseudo-angina.
This is a common affection in women, but may occur also in neuras-
thenic men. It is in this form particularly that we see vaso-motor phe-
nomena. The patient may complain of great coldness of the hands or
feet, or a general feeling of deadness and stiffness, often with pain in the
back of the head and neck. The attacks recur frequently, and sometimes
become worse at each monthly period. They may come on with great
severity at the menopause. Worry and disturbing emotions of all kinds
may at any time precipitate an attack. Iluchard has given in concise
form the following points in diagnosis between the true and hysterical
angina :
658 DISEASES OF THE CIRCULATORY SYSTEM.
TRUE ANGINA. PSEUDO-ANGINA.
Most common between the ages At every age, even six years,
of forty and fifty years.
Most common in men. Attacks Most common in women. At-
brought on by exertion. tacks spontaneous.
Attacks rarely periodical or noc- Often periodical and nocturnal,
turnal.
Not associated with other symp- Associated with nervous symp-
toms, toms.
Vaso-motor form rare. Agoniz- Vaso-motor form common,
ing pain and sensation of compres- Pain less severe ; sensation of dis-
sion by a vise. tention.
Pain of short duration. Atti- Pain lasts one or two hours,
tude : silence, immobility. Agitation and activity.
Lesions : sclerosis of coronary Neuralgia of nerves and cardio-
artery. plexus.
Prognosis grave, often fatal. Never fatal.
Arterial medication. . Antineuralgic medication.
There are cases in women which are sometimes very puzzling; for
instance, when the patient presents a combination of marked hysterical
manifestations and attacks of angina and has aortic insufficiency. In
such instances the patient should receive the benefit of the doubt and
be treated for true angina.
Prognosis. — Cardiac pain without evidence of arterio-sclerosis or
valve disease is not of much moment. True angina is almost invariably
associated with marked cardio-vascular lesions in which the prognosis is
always grave. AVith judicious treatment the attacks, however, may be
long deferred, and a few instances recover completely. The prognosis is
naturally more serious with aortic insufficiency and advanced arterio-
sclerosis. Patients who have had well-marked attacks may live for many
years, but much depends upon the care with which they regulate their
daily life.
Treatment. — Patients subject to this affection should live a quiet
life, avoiding particularly excitement and sudden muscular exertion.
During the attack nitrite of ainyl should be inhaled, as advised by Lauder
Brunton. From two to five drops may be placed upon cotton-wool in a
tumbler or upon the handkerchief. This is frequently of great service in
the attack, relieving the agonizing pain and distress. Subjects of the dis-
ease should carry the perries of the nitrite of amyl with them, and use them
on the first indication of an attack. In some instances the nitrite of amyl
is quite powerless, though given freely. If within a minute or two relief is
not obtained in this way, chloroform should at once be given. A few in-
halations act prom})tly and give great relief. Should the pains continue,
a hypodermic of morphia may be administered.
CONGENITAL AFFECTIONS OF THE HEART. 659
In the intervals, nitroglycerin may be given in full doses, as recom-
mended by Murrell, or the nitrite of sodium (Matthew Hay). The nitro-
glycerin should be used for a long time and in increasing doses, beginning
with one minim three times a day of the one per cent solution, and in-
creasing the dose one minim every five or six days until the patient com-
plains of flushing or headache.
Huchard recommends the iodides, believing that their prolonged use
influences the arterio-sclerosis. Twenty grains three times a day may be
given for several years, omitting the medicine for about ten days in each
month. In some instances this treatment is certainly beneficial. Two
men, both with arterio-sclerosis, ringing, accentuated aortic sound, and
attacks of true angina, have under its use remained practically free from
attacks — one case for nearly three, and the other for fully four years.
This treatment is, however, not always satisfactory, and I have had several
cases in which the condition has not been at all relieved by it.
For the pseudo-angina, the treatment must be directed to the general
nervous condition. Electricity is sometimes very beneficial, particularly
the Franklinic form.
VI. CONGENITAL AFFECTIONS OF THE HEART.
These have only a limited clinical interest, as in a large propor-
tion of the cases the anomaly is not compatible with life, and in others
nothing can be done to remedy the defect or even to relieve the symp-
toms.
The congenital affections result from interruption of the normal course
of development or from inflammatory processes — endocarditis ; sometimes
from a combination of both.
(a) Of general cmomalies of development the following conditions may
be mentioned : Acardia, absence of the heart, which has been met with
in the monstrosity known by the same name ; double hearty which has
occasionally been found in extreme grades of foetal deformity ; dextro-
cardia^ in which the heart is on the right side, either alone or as part of
a general transposition of the viscera ; ectopia cordis, a condition asso-
ciated with fission of the chest wall and of the abdomen. The heart may
be situated in the cervical, pectoral, or abdominal regions. Except in the
abdominal variety the condition is very rarely compatible with extra-
uterine life.
(Ij) Anomalies of the Cardiac Septa. — The septa of both auricles and
ventricles may be defective, in which case the heart consists of but two
chambers, the cor biloculare or reptilian heart. In the septum of the auri-
cles there is a very common defect, owing to the fact that the membrane
closing the foramen ovale has failed at one point to become attached to the
ring, and leaves a valvular slit which may be large enough to admit the
eoO DISEASES OF THE CIRCULATORY SYSTEM.
handle of a scalpel. Neither this nor the small cribriform perforations of
the membrane are of any significance.
The foramen ovale may be patent without a trace of membrane clos-
insr it. In some instances this exists with other serious defects, such as
stenosis of the pulmonary artery, or imperfection of the ventricular sep-
tum. In others the patent foramen ovale is the only anomaly, and in
many instances it does not appear to have caused any embarrassment, as
the condition has been found in persons who have died of various affections.
Tlie ventricular septum may be absent, the condition known as trilocular
heart. Much more frequently there is a small defect in the upper portion
of the septum, either in the situation of the membranous portion known
as the " undefended space " or in the region situated just anterior to this.
The anomaly is very frequently associated with narrowing of the pul-
monary orifice or of the conus arteriosus of the right ventricle.
(c) Anomalies and Lesions of the Valves. — Numerical anomalies of the
valve are not uncommon. The semilunar segments at the arterial orifices
are not infrequently increased or diminished in number. Supernumer-
ary segments are more frequent in the pulmonary artery than in the aorta*
Four, or sometimes five, valves have been found. The segments may be of
equal size, but, as a rule, the supernumerary valve is small.
Instead of three there may be only two semilunar valves, or, as it is
termed, the hicusjjid condition. In my experience, this is most frequent
in the aortic valve. Of twenty-one instances only two occurred at the
pulmonary orifice. Two of the valves have united, and from the ventricu-
lar face show either no trace of division or else a slight depression indicat-
ing where the union had occurred. From the aortic side there is usually
to be seen some trace of division into two sinuses of Valsalva. There has
been a discussion as to the origin of this condition, whether it is really an
anomaly or whether it is not due to endocarditis, fcetal or post-natal. The
combined segment is usually thickened, but the fact that this anomaly is
met with in the foetus without a trace of sclerosis or endocarditis shows
that it may, in some cases at least, result from a developmental error.
Clinically this is a very important congenital defect, owing to the
liability of the combined valve to sclerotic changes. Except two foetal
specimens all of my cases showed thickening and deformity, and in fifteen
of those which I have reported death resulted directly or indirectly from
the lesion.
The little fenestrations at the margins of the sigmoid valves have no
significance ; they occur in a considerable proportion of all bodies.
Anomalies of the auriculo-ventricular valves are not often met with.
Foetal endocarditis may occur either at the arterial or auriculo-ven-
tricular orifices. It is nearly always of the chronic or sclerotic variety.
Very rarely indeed is it of the warty or verrucose form. There are little
nodular bodies, sometimes six or eight in number, on the mitral and tri-
cuspid segments — the nodules of Albini — which represent the remains of
CONGENITAL AFFECTIONS OF THE HEART. CGI
foetal structures, and must not be mistaken for endocardial outgrowths.
The little rounded, bead-like haemorrhages of a deep purjjle color, which
are very common on the heart valves of children, are also not to be mis-
taken for the products of endocarditis. In f a3tal endocarditis the segments
are usually thickened at the edges, shrunken, and smooth. In the mitral
and tricusjiid valves the cusps are found united and the chordae tendineae
are thickened and shortened. In the semilunar valves all trace of the
segments has disappeared, leaving a stiff membranous diaphragm perfo-
rated by an oval or rounded orifice. It is sometimes very difficult to say
whether this condition has resulted from foetal endocarditis or whether it
is an error in development. In very many instances the processes are
combined ; an anomalous valve becomes the seat of chronic sclerotic
changes, and, according to Rauchfuss, endocarditis is more common on
the right side of the heart only because the valves are here most often the
seat of developmental errors.
Lesions at the Pulmonary Orifice. — Stenosis of this orifice is one of the
commonest and most important of congenital heart affections. A slow
endocarditis causes gradual union of the segments and narrowing of the
orifice to such a degree that it only admits the smallest-sized probe. In
some of the cases the smooth membranous condition of the combined
segments is such that it would appear to be the result of faulty develop-
ment. In some instances vegetations develop. The condition is com-
patible with life for many years, and in a considerable proportion of the
cases of heart-disease above the tenth year this lesion is present. \Yith it
there may be defect of the ventricular septum. Obliteration or atresia of
the pulmonary orifice is less frequent but a more serious condition than
stenosis. It is of necessity associated with either imperfection of the ven-
tricular septum or patency of the foramen ovale and persistence of the
ductus arteriosus. Stenosis of the conus arteriosus of the right ventricle
exists in a considerable proportion of the cases of obstruction at the pul-
monary orifice. At the outset a developmental error, it may be combined
with sclerotic changes. The ventricular septum is imperfect, the foramen
ovale is usually open, and the ductus arteriosus patent. These three lesions
at the pulmonary orifice constitute the most important group of all con-
genital cardiac affections. Of 181 instances of various congenital anoma-
lies collected by Peacock 119 cases came under this category, and, accord-
ing to this author, in eighty-six per cent of the patients with congenital
heart-disease living beyond the twelfth year the lesion is at this orifice.
Congenital lesions of the aortic orifice are not very frequent. Rauch-
fuss has collected 24 cases of stenosis and atresia, and stenosis of the left
conus arteriosus may also occur, a condition which is not incompatible
with prolonged life. Ten of the sixteen cases tabulated by Dilg were
over thirty years of age.
Symptoms of Congenital Heart-disease. — Cyanosis occurs in
over ninety per cent of the cases and forms so distinctive a feature that
662 DISEASES OF THE CIRCULATORY SYSTEM.
the terms " blue disease " and " morbus caeruleus " are practically
synonyms for congenital heart-disease. The lividity in a majority of
cases appears early, within the first week of life, and may be general or
confined to the lips, nose, and ears, and to the fingers and toes. In some
instances there is in addition a general dusky suffusion, and in the most
extreme grades the skin is almost purple. It may vary a good deal and
may only be intense on exertion. The external temperature is low.
Dyspnoea on exertion and cough are common symptoms. The children
rarely thrive and often display a lethargy of both mind and body. The
fingers and toes are clubbed in a grade rarely met with in any other affec-
tion. The cause of the cyanosis has been much discussed. Morgagni
referred it to the general congestion of the venous system due to obstruc-
tion, and this view was supported in a paper, one of the ablest that has
been written on the subject, by Moreton Stille. Morrison's recent analysis
of 75 cases of congenital heart-disease shows that closure of the pulmonary
orifice and patency of the foramen ovale and the ventricular septum are
the lesions most frequently associated with cyanosis, and he concludes that
the deficient aeration of the blood owing to diminished lung function is
the most important factor. Another view, advocated by William Hunter,
was that the discoloration was due to the admixture in the heart of venous
and arterial blood ; but lesions may exist which permit of very free mixt-
ure without producing cyanosis.
Diagnosis. — In the case of children, cyanosis, with or without en-
largement of the heart, and the existence of a murmur are sufficient, as a
rule, to determine the presence of a congenital heart-lesion. The cyano-
sis gives us no clew to the precise nature of the trouble, as it is a symptom
common to many lesions and it may be absent in certain conditions. The
murmur is usually systolic in character. It is, however, not always pres-
ent, and there are instances on record of complicated congenital lesions in
which the examination showed normal heart-sounds. In two or three
instances foetal endocarditis has been diagnosed in gravida by the pres-
ence of a rough systolic murmur, and the condition has been corroborated
subsequent to the birth of the child. Hypertrophy is present in a major-
ity of the cases of congenital defect. It is impossible in the scope of a
work of this sort to enter upon elaborate details in differential diagnosis
between the various congenital heart-lesions. I here abstract the conclu-
sions on this question given by Ilochsinger in his recent monograph : *
" (I) In childhood, loud, rough, musical heart-murmurs, with normal
or only slight increase in the heart-dulness, occur only in congenital heart-
disease. Tlie acquired endocardial defects with loud heart-murmurs in
young children are almost always associated with great increase in tlie
heart-dulness.
*' (2) In young children heart-murmurs with great increase in the
* Die Auscultation des kindlichen Herzens, Wien, 1890.
DEGENERATIONS. GC3
cardiac dulness and feeble apex beat suggest congenital changes. I'hc
increased dulness is chiefly of the right heart, whereas the left is only
slightly altered. On the other hand, in the acquired endocarditis in chil-
dren, the left heart is chiefly affected and the apex beat is visible ; the
dilatation of the right heart comes late and does not materially change
the increased strength of the apex beat.
" (3) The entire absence of murmurs at the apex, with their evident
presence in the region of the auricles and over the pulmonary orifice, is
always an important element in differential diagnosis, and points rather
to septum defect or pulmonary stenosis than to endocarditis.
" (4) An abnormally weak second pulmonic sound associated with a
distinct systolic murmur is a symptom which in early childhood is only to
be explained by the assumption of a congenital pulmonary stenosis, and
possesses therefore an importance from a point of differential diagnosis
which is not to be underestimated.
" (5) Absence of a palpable thrill, despite loud murmurs which are
heard over the whole prgecordial region, is rare except with congenital
defects in the septum, and it speaks therefore against an acquired cardiac
affection.
" (6) Loud, especially vibratory, systolic murmurs, with the point of
maximum intensity over the upper third of the sternum, associated with
a lack of marked symptoms of hypertrophy of the left ventricle, are very
important for the diagnosis of a persistence of the ductus Botalli, and can-
not be explained by the assumption of an endocarditis of the aortic valve."
Treatment. — The child should be warmly clad and guarded from all
circumstances liable to excite bronchitis. In the attacks of urgent dysp-
noea with lividity blood should be freely let. Saline cathartics are also
useful. Digitalis must be used with care, and it is sometimes beneficial in
the later stages. When the compensation fails, the indications for treat-
ment are those of valvular disease in adults.
III. DISEASES OF THE AETEEIES.
I. DEGENERATIONS.
Fatty degeneration of the intima is extremely common, and is seen in
the form of yellowish-white spots in the aorta and larger vessels. Calcifica-
tion of the arterial wall follows fatty degeneration, atheromatous changes,
and sclerosis. It occurs in either the intima or the media. In the latter
it produces what is sometimes known as annular calcification, which oc-
curs particularly in the middle coat of medium-sized vessels and may con-
vert them into firm tubes. Calcification of the intima is a common
terminal process of arterio-sclerosis.
064 DISEASES OF THE CIRCULATORY SYSTEM.
Ilyaline degeneration may attack either tlie larger or the smaller
vessels. In the former the intima is converted into a smooth, homogeneous
substance, and it is commonly an initial stage of arterio-sclerosis. In the
smaller arteries and capillaries the hyaline degeneration is often seen,
particularly in the glomeruli of the kidney. Its exact production is still
a matter of some doubt. " It appears to arise principally by homogeneous
coagulation of an albuminous fluid, either within the vessels or infiltrating
the cells and the hyaline transformation of proliferating cells and of leu-
cocytes."
1 1 . A RTE R I O-SC LE ROS I S {Arterio-capillary Fibrosis).
The conception of arterio-sclerosis as an independent affection — a gen-
eral disease of the vascular system — is due to Gull and Sutton.
Definition. — A condition of thickening, diffuse or circumscribed, of
the intima, consequent upon primary changes in the media and adventitia.
The process leads, in the larger arteries, to what is known as atheroma or
endarteritis deformans.
Etiology. — (1) As an involution process arterio-sclerosis is an ac-
companiment of old age, and is the expression of the natural wear and
tear to which the tubes are subjected. Longevity is a vascular question,
and has been well expressed in the axiom that " a man is only as old as
his arteries." To a majority of men death comes primarily or secondarily
through this portal. The onset of what may be called physiological
arterio-sclerosis depends, in the first place, upon the quality of arterial tis-
sue (vital rubber) which the individual has inherited, and secondly upon
the amount of Avear and tear to which he has subjected it. That the
former plays the most important role is shown in the cases in which
arterio-sclerosis sets in early in life in individuals in whom none of the
recognized etiological factors can be found. Thus, for instance, a man
of twenty-eight or twenty-nine may have arteries of sixty, and a man
of forty may present vessels as much degenerated as they should be at
eighty. Entire families sometimes show this tendency to early arterio-
sclerosis, a tendency which cannot be explained in any other way than
that in the make-up of the machine bad material was used for the
tubing.
More commonly the arterio-sclerosis results from the bad use of good
vessels, and among the circumstances which tend to produce this condi-
tion are the following :
(2) Chronic Intoxications. — Alcohol, lead, gout, and syphilis play an
important role in the causation of arterio-sclerosis, although the precise
mode of their action is not yet very clear. They may act, as Traube sug-
gests, by increasing the peripheral resistance in the smaller vessels and in
this way raising the blood tension, or possibly, as Bright taught, they alter
ARTERIO-SCLEROSIS. 6G5
the qualit}' of the blood and render more difficult its passage through the
capillaries.
The poison of syphilis and of gout may act directly on the arteries,
producing degenerative changes in the media and adventitia.
(3) Overeating. — Many authors attribute an important part of the
etiology of arterio-sclerosis to the overfilling of the blood-vessels which
occurs when unnecessarily large quantities of food and drink are taken.
Particularly is this the case in stout persons who take very little exercise.
(4) Overwork of the muscles., which acts by increasing the peripheral
resistance and by raising the blood-pressure.
(5) Renal Disease. — The relation between the arterial and kidney
lesions has been much discussed, some regarding the arterial degenera-
tion as secondary, others as primary. There are certainly two groups of
cases, one in which the arterio-sclerosis is the first change, and the other
in which it appears to be secondary to a primary affection of the kidneys.
The former occurs, I believe, with much greater frequency than has been
supposed.
Morbid Anatomy. — Thoma divides the cases mto primary arterio-
sclerosis, in which there are local changes in the arteries leading to dilata-
tion and a compensatory increase of the connective tissue of the intima ;
secondary arterio-sclerosis, due to changes in the arteries which follow
increased resistance to the blood-flow in the peripheral vessels. This in-
creased tension leads to dilatation and to slowing of the blood-stream and
a secondary compensatory development of the intima.
In a recent study of 41 autopsies upon arterio-sclerotic cases from my
wards. Councilman * follows the useful division into nodular, senile, and
diffuse forms.
(a) Nodular Form. — In the circumscribed or nodular variety the ma-
croscopic changes are very characteristic. The aorta presents, in the early
stages, from the ring to bifurcation, numerous flat projections, yellowish
or yellowish white in color, hemispherical in outline, and situated par-
ticularly about the orifices of the branches. In the early stage these
patches are scattered and do not involve the ei.tire intima. In more ad-
vanced grades the patches undergo atheromatous changes. The material
constituting the button undergoes softening and breaks up into granu-
lar material, consisting of molecular debris — the so-called atheromatous
abscess.
In the circumscribed or nodular arterio-sclerosis the primary alteration
consists in a degeneration or a local infiltration in the media and adven-
titia, chiefly about the vasa vasorum. The affection is really a mesarteritis
and a periarteritis. These changes lead to the weakening of the wall in
the affected area, at which spot the proliferative changes commence in the
intima, particularly in the subendothelial structures, with gradual thick-
♦ Transactions of the Association of American Physicians, vol. vi.
606 DISEASES OF THE CIRCULATORY SYSTEM.
ening and the formation of an atheromatous button or a patch of nodular
arterio-sclerosis. Tlie researches of Thoma have shown that this is really
a compensatory process, and that before its degeneration the nodular but-
ton, wliich post mortem projects beyond the lumen, during life fills up
and obliterates what would otherwise be a depression of the wall in conse-
quence of the weakening of the media. A similar process goes on in the
smaller vessels, and in any one of the smaller branches it can be readily
seen on section that each patch of endarteritis corresponds to a defect in
the media and often to changes in the adventitia. The condition is one
which may lead to rajoid dilatation or to the production of an aneurism,
particularly in the early stage, before the weakened spot is thickened and
strengthened by the intimal changes.
(b) Senile Arteriosclerosis. — The larger arteries are dilated and tort-
uous, the walls thin but stiff, and often converted into rigid tubes. The
subendothelial tissue undergoes degeneration and in spots breaks down,
forming the so-called atheromatous abscesses, the contents of which con-
sist of a molecular debris. They may open into the lumen, when they
are known as atheromatous ulcers. The greater portion of the intima
may be occupied by rough calcareous plates, with here and there fissures
and losses of substance, upon which not infrequently white thrombi are
deposited. Microscopically there is extreme degeneration of the coats,
particularly of the media. Senile atrophy of the liver and kidneys usually
accompanies these changes. Senile changes are common in other organs.
The heart may be small and is not necessarily h3rpertrophied. In 7 of 14
cases of Councilman's series there was no enlargement. Brown atrophy
is common
(c) Diffuse Arterio-sclerosis. — The process is wide-spread throughout
the aorta and its branches, in the former usually, but not necessarily, asso-
ciated with the nodular form. The subjects of this variety are usually
middle-aged men, but it may occur early. Of the 27 in Councilman's
series belonging to this group the majority were between the ages of forty
and fifty-five. The youngest was a negro of twenty-three and the oldest a
man of sixty. The affection is very prevalent among negroes ; less than
fifty per cent were in whites, whereas the ratio of colored to white patients
in the wards is one to seven. The affection is met with in strongly built,
muscular men and, as Councilman remarks, they rarely present on the
autopsy table signs of general anasarca or, if oedema exists, it has come
on during the last few days of life.
The aorta and its branches are more or less dilated, the branches some-
times more than the trunk. The intima may be smooth and show very
slight changes to the naked eye ; more commonly there are scattered ele-
vated areas of an opaque white color, some of which may have undergone
atheromatous changes as in the senile form. Microscopically the media
shows necrotic and hyaline changes, involving in the larger arteries both
muscular and elastic elements, and the intima presents a great increase
ARTERIO-SCLEROSIS. 607
in the subendotlielial connective tissue, which is particularly marked oppo-
site areas of advanced degeneration in the media. The small arteries —
those of the kidneys, for example — show " a thickening of the wall, due to
the formation of a homogeneous hyaline tissue within the muscular coat.
This tissue contains but few cells, is faintly striated, and stains a light
brown in the osmic acid used in the hardening solution. In many of the
smallest vessels nothing can be seen of the elastic lamina, in others only
fragments can be made out, in others it is preserved. . . . The muscular
fibres of the media show marked atrophic changes. Fatty degeneration
of the cells can be made out both in fresh sections and after hardening
in Fleming's solution. The nuclei are thin and atrophic and vacuoles are
sometimes seen in them. In some arteries the muscle-fibres have almost
disappeared and the media is changed into a homogeneous tissue, similar
to that in the thickened intima" (Councilman). The degeneration of
the media is most marked in the smaller arteries. The capillaries are
thickened, particularly those of the glomeruli of the kidneys, which are
often obliterated and involved in extensive hyaline degeneration.
It is in this group of cases that the heart shows the most important
changes. The average weight in the cases referred to was over 450
grammes, and there were two cases in which without valvular disease
the weight was over 800 grammes. Fibrous myocarditis is often present,
particularly when the coronary arteries are involved. The semilunar
valves are sometimes opaque and sclerotic, and may be incompetent. The
kidneys may show extensive sclerosis, but in many cases the changes are
so slight that macroscopically they might be overlooked. They may be
increased in size. The capsule is usually adherent, the surface a little
rough, and very often presents atrophic areas at a lower level of a deep-
red color. Increased consistence is always present.
Sclerosis of the pulmo7iary artery is met with in all conditions which
for a long time increase the tension in the lesser circulation, particularly
in mitral-valve disease and in emphysema. Sometimes the sclerosis reaches
a high grade and is accompanied with aneurismal dilatation of the primary
and secondary branches, more rarely with insufficiency of the pulmonary
valve. In a remarkable case of a young man of twenty-four, reported by
Romberg from Curschmann's clinic, the pulmonary arteries were involved
in most extensive arterio-sclerosis ; the main branches were dilated, and the
smaller branches were the seat of the most extreme sclerotic changes. On
the other hand, the aorta and its branches were normal. The heart was
greatly hypertrophied, and the clinical symptoms were those of a congeni-
tal heart affection. In many cases of arterio-sclerosis the condition is not
confined to the arteries, but extends not only to the capillaries but also to
the veins, and may properly be termed amjio-sclerosis.
Sclerosis of the veins — -jy/i/eJo-^c/ero^is — is not at all an uncommon
accompaniment of arterio-sclerosis, and is a condition to which of late a
good deal of attention has been paid. It is seen in conditions of height-
43
668 DISEASES OF THE CIRCULATORY SYSTEM.
ened blood -pressure, as in the portal system in cirrhosis of the liver and in
the pulmonary veins in mitral stenosis. The affected vessels are usually
dilated, and the intima shows, as in the arteries, a compensatory thicken-
ing, which is particularly marked in those regions in which the media is
tliinned. The new-formed tissue in the endophlebitis may undergo hya-
line degeneration, and is sometimes extensively calcified. In a case of
fibroid obliteration of the portal vein of long standing, I found the intima
of the greatly dilated gastric, splenic, and mesenteric extensively calcified.
In ordinary diffuse arterio-sclerosis the veins may also be involved, but
rarely to a marked degree.
Symptoms. — Many patients never come under observation during
life, but are seen for the first time on the post-mortem table, having died
suddenly from cerebral haemorrhage, blocking of a coronary artery, or
rupture of an aneurism.
Among important symptoms are the following :
Increased Tension. — The pressure wdth which the blood flows in the
arteries depends upon the degree of peripheral resistance and the force of
the ventricular contraction. A high-tension pulse may exist with very
little arterio-sclerosis ; but, as a rule, when the condition has been per-
sistent, the sclerosis and high tension are found together. The pulse
wave is slow in its ascent, enduring, subsides slowly, and in the intervals
of the beats the vessel remains full and firm. It may be very difficult to
obliterate the pulse, and the firmest pressure on the radial or the tem-
poral may not be sufficient to annihilate the pulse wave beyond the point
of pressure. The sphygmographic tracing shows a sloping, short up-
stroke, no percussion wave, and a slow, gradual descent, in which the
dicrotic wave is very slightly marked. It may be difficult to estimate
how much of the hardness and firmness is due to the tension of the blood
within the vessel, and how much to the thickening of the wall. If, for
example, when the radial is compressed with the index-finger the artery
can be felt beyond the point of compression, its walls are sclerosed.
Hypertrophy of the Heart. — In consequence of the peripheral resist-
ance and increased work the left ventricle increases in size, and some of
the purest examples of simple hypertrophy occur in this condition. The
chamber may be little, if at all, dilated. The apex beat is dislocated in
advanced cases an inch or more beyond the nipple line. The impulse is
heaving and forcible. The aortic second sound is clear, ringing, and
accentuated.
Tlie combination of increased arterial tension, a palpable thickening
of the arteries, hypertrophy of the left ventricle, and accentuation of the
aortic second sound are signs pathognomonic of arterio-sclerosis. From
this period of establishment the course of the disease may be very varied.
For years the patient may maintain good health, and be in a condition
analogous to a person with a well-compensated valvular lesion. There
may be no renal symptoms, or there may be the passage of a larger
ARTERIO-SCLEROSIS. CC9
amount of urine than normal, witli transient albuminuria, and now and
then hyaline tube-casts. The subsequent history is extraordinarily diverse,
depending upon the vascular territory in which the sclerosis is most ad-
vanced, or upon the accidents which are so liable to hai:)pen, and the
symptoms may be cardiac, cerebral, renal, etc.
(1) Cardiac. — The involvement of the coronary arteries may lead to
the various symptoms already referred to under that section — thrombosis
with sudden death, fibroid degeneration of the heart, aneurism of the
heart, rupture, and angina pectoris. Angina pectoris is extremely com-
mon, and in the true variety is almost always associated with arterio-scle-
rosis. A second important group of cardiac symptoms results from the
dilatation which ultimately may follow the hypertrophy. The patient
then presents all the symptoms of cardiac insufficiency — dyspnoea, scanty
urine, and very often serous effusions. If the case has come under obser-
vation for the first time the clinical picture is that of chronic valvular dis-
ease, and the existence of a loud blowing murmur at the apex may throw
the practitioner off his guard. Many cases terminate in this way.
(2) The cerebral symptoms of arterio-sclerosis are varied and important,
and embrace those of many degenerative processes, acute and chronic (which
follow sclerosis of the smaller branches), and cerebral haemorrhage, which
is usually associated with the miliary aneurisms.
Transient hemiplegia, monoplegia, or aphasia may occur in advanced
arterio-sclerosis. Recovery may be perfect. It is difficult to say upon
what these attacks depend. Spasm of the arteries has been suggested, but
the condition of the smaller arteries is not very favorable to this view.
Peabody has recently called attention to these cases, which are more com-
mon than indicated in the literature.
(3) Renal symptoms supervene in a large number of the cases. A
sclerosis, patchy or diffuse, is present in a majority of the cases at the time
of autopsy, and the condition is practically that of contracted kidneys. It
is seen in a typical manner in the senile form, and not infrequently devel-
ops early in life as a direct sequence of the diffuse variety. It is often
difficult to decide clinically (and the question is one upon which good ob-
servers might not agree in a given case) whether the arterial or the renal
disease has been primary.
(4) Among other events in arterio-sclerosis may be mentioned gan-
grene of the extremities, due either directly to endarteritis or to the dis-
lodgment of thrombi. Respiratory symptoms are not uncommon, particu-
larly bronchitis and the symptoms associated with emphysema.
Treatment. — In the late stages the conditions must be treated as
they arise in connection with the various viscera. In the early stages, be-
fore any local symptoms are manifest, the patient should be enjoined to
live a quiet, well-regulated life, avoiding excesses in food and drink. It
is usually best to explain frankly the condition of affairs, and so gain his
intelligent co-operation. Special attention should be paid to the state of
070 DISEASES OP THE CIRCULATORY SYSTEM.
the bowels and urine, and the secretion of the skin should be kept active
by daily baths. Alcohol in all forms should be prohibited, and the food
should be restricted to plain, wholesome articles. The use of mineral
waters or a residence every year at one of the mineral springs is usually
serviceable. If there has been a syphilitic history an occasional course of
iodide of potassium is indicated, and whenever the pulse tension is high
nitroglycerine may be used.
In cases which come under observation for the first time with dyspnoea,
slight lividity, and signs of cardiac insufficiency, venesection is indicated.
In some instances, with very high tension, striking relief is afforded by the
abstraction of twenty ounces of blood.
III. ANEURISM.
The following forms of aneurism are usually recognized :
(a) The true^ in which the sac is formed of one or more of the arterial
coats. This may be fusiform, cylindrical, or cirsoid (in which the dilatation
is in an artery and its branches), or it may be circumscribed or sacculated.
Aneurisms are usually fusiform, resulting from uniform dilatation of the
vessel, or saccular.
(b) The false or dissecting aneurism, which results from injury or
laceration of the internal coat. The blood dissects between the layers ;
hence the name, dissecting aneurism. This occurs usually in the aorta.
It may dissect the entire length of the vessel, and, perforating into the
lumen of the vessel, may, as in a case reported by J. E. Graham, persist
for years.
(c) Arterio-venous aneurism results when a communication is estab-
lished between an artery and a vein. A sac may intervene, in which case
it is called a varicose aneurism ; but in many cases the communication is
direct and the chief change is in the vein, which is dilated, tortuous, and
pulsating, and is termed an aneurismal varix.
Etiology and Pathology. — Aneurisms arise : {a) By the gradual
diffuse distention of the arterial coats, which have been weakened by
arterio-sclerosis, particularly in its early stages, before compensatory en-
darteritis develops. The arch of the aorta is often dilated in this way so
as to form an irregular aneurism.
(h) In consequence of circumscribed loss of resisting power in the
media and adventitia, and due often to laceration of the media. This is
the most common cause of sacculated aneurism. The laceration is fre-
quently found in the ascending portion of the arch and occurs early in
tlie process of arterio-sclerosis, before the compensatory thickening has
taken place. Occasionally one meets with remarkable specimens illustrat-
ing the important part played by this process. The intima may also
be torn. In a case of Daland's there was just above the aortic valves
ANEURISM. 671
an old transverse tear of the intima, extending almost the entire circumfer-
ence of the vessel. Sclerosis of the media and adventitia had taken place
and the process was evidently of some standing. An inch or more above
it was a fresh transverse rent which had produced a dissecting aneurism.
These arterio-sclerotic aneurisms, as they are called, are found also in the
smaller vessels.
(c) Embolic Aneurism. — When an embolus has lodged in a vessel and
permanently plugged it, aneurismal dilatation may follow on the proximal
side. The embolus itself may, if a calcified fragment from a valve, lacer-
ate the wall, or if infected may produce inflammation and softening. In
either case aneurism may result.
(d) Mycotic jhieurism. — The importance of this form has been spe-
cially considered by Eppinger in his exhaustive monograph. The occur-
rence of multiple aneurisms in malignant endocarditis has been observed
by several writers. Probably the first case in which the mycotic nature
was recognized was one which occurred at the Montreal General Hospital
and is reported in full in my lectures on malignant endocarditis. In addi-
tion to the ulceration of the valves there were four aneurisms of the arch,
of which one was large and saccular, and three were not bigger than
cherries. An extensive growth of micrococci was present in the larger as
well as in the smaller sacs.
A form of parasitic aneurism which occurs with great frequency in
the mesenteric arteries of the horse is due to the development of the
strongylus armatus.
And, lastly, there are cases in which without any definite cause there
is a tendency to the development of aneurisms in various parts of the
body. A remarkable instance of it in our profession was afforded by the
brilliant Thomas King Chambers, who first had an aneurism in the left
popliteal artery, eleven years subsequently an aneurism in the right leg
which was cured by pressure, and finally aneurism of both carotid arteries.
Aneurism of the Thoracic Aorta.
The causes which favor the development of arterio-sclerosis prevail in
aortic aneurism, particularly alcohol, syphilis, and overwork. The great-
est danger probably is in strong muscular men with commencing degen-
erative processes in the arteries (a consequence of syphilis or alcohol or a
result of hereditary weakness of the arterial tissues), who during a sudden
muscular exertion are liable to lacerate the media, the intima not yet being
strengthened by compensatory thickening over a spot of mesarteritis.
Aneurisms of the thoracic aorta vary greatly in size and shape. A major-
ity of them are saccular. They may be small and situated just above the
aortic ring. Others form large tumors which project externally and occupy
a large portion of the upper thorax. Small sacs from the descending por-
tion of the arch may compress the trachea or the bronchi. In the tho-
(572 DISEASES OF THE CIRCULATORY SYSTEM.
racic portion the sac may erode the vertebrae or grow into the pleural cavity
and compress tlie lung. In some instances it grows through the ribs and
appears in the back.
Symptoms. — The chief influence of an aneurism is manifested in
what are known as pressure effects. In the absence of these the aneurisms
attain a large size without producing symptoms or seriously interfering
Avith the circulation. Indeed, a useful clinical subdivision as given by
Bramwell is into three groups — aneurisms which are entirely latent and
give no physical signs ; aneurisms which present signs of intrathoracic
pressure, but it is difficult or impossible to determine the nature of the
lesion producing the pressure ; and, lastly, aneurisms which produce dis-
tinct tumors with well-marked pressure symptoms and external signs. It is
perhaps best to consider aneurisms of the aorta according to the situation
of the tumor.
(a) Aneurisins of the Ascending Portion of the Arch. — When just
above the sinuses of Valsalva they are often small and latent. The first
symptom may be rupture, which usually takes place into the pericardium
and causes instant death. Above the sinuses, along the convex border of
the ascending part, aneurism frequently develops, and may grow to a
large size, either passing out into the right pleura or forward, pointing at
the second or third interspace, eroding the ribs and sternum, and produc-
ing large external tumors. In this situation the sac is liable indeed to
compress the superior vena cava, causing engorgement of the vessels of
the head and arm, sometimes compressing only the subclavian vein, and
causing enlargement and oedema of the right arm. Perforation may take
place into the superior vena cava, of which accident Pepper and Griffith
have collected twenty-nine cases. Large aneurisms in this situation may
cause much dislocation of the heart, pushing it down and to the left,
and sometimes compressing the inferior vena cava, and causing swelling
of the feet and ascites. The right recurrent laryngeal nerve is often in-
volved in these tumors. Death commonly follows from rupture into the
pleura, or into the superior cava ; less commonly from rupture externally,
sometimes from heart-failure.
{b) Aneurisms of the Transverse Arch. — These may grow forward,
erode the sternum, and produce large tumors. More commonly they are
small and produce no external tumor, but cause marked pressure signs in
their growth backward toward the spine, involving the trachea and the
oesophagus, producing cough, which is often of a paroxysmal character,
and dysphagia. The left recurrent laryngeal is often involved in its
course round the arch. A small aneurism from the lower or posterior
wall of tlie arch may compress a broncluis, inducing bronchorrhoea,
gradual bronchiectasy, and suppuration in the lung — a process which by
no means infrequently causes death in aneurism, and a condition which
at tlie Montreal General Hospital we were in the habit of terming aneu-
rismal phthisis. Occasionally enormous aneurisms develop in this situa-
ANEURISM. 673
tion, and grow into botli pleurae, extending between the manubrium and
the vertebrse, and may persist for years. The sac may be evident at the
sternal notch. The innominate, less commonly the left carotid and sub-
clavian, may be involved in the sac,, and the radial or carotid pulse may
be absent or retarded. Pressure on the sympathetic may at first cause
dilatation and subsequently contraction of the pupil. Sometimes the
thoracic duct is compressed.
(c) Aneurisms of the Descending Portion. — Pressure signs are not so
marked. The pain is often intense, owing to erosion of the vertebrae.
Dysphagia may occur. Compression of the lung or compression of cer-
tain bronchi may induce bronchiectasy, retention of secretions, and fever.
A tumor may appear externally in the region of the scapula, and here
attain an enormous size. Occasionally the aneurisms in this region are
small and latent, and prove fatal by rupture into the oesophagus. I have
reported a case of sudden death, in which the heart and arch of the aorta
were normal and the stomach was distended with blood, which could not
be accounted for until the oesophagus was slit open, when it was found
that a small aneurism in the thoracic aorta, smaller than a w^alnut, had
ruptured into the gullet. The sac may erode the vertebrae and open the
spinal canal, producing compression of the cord. Death not infrequently
occurs from rupture into the pleura.
Diagnosis and Physical Signs. — Inspection. — In many instances
this is negative. On either side of the sternum there may be abnormal
pulsation, due to dislocation of the heart or to deformity of the thorax.
The aneurismal pulsation is usually above the level of the third rib and
most commonly to the right of the sternum, either in the first or second
interspace. It may be only a diffuse heaving impulse without any exter-
nal tumor. Often the impulse is noticed only when the chest is looked
at obliquely in a favorable light. When the innominate is involved the
throbbing may pass into the neck or be apparent at the sternal notch.
Posteriorly, when pulsation occurs, it is most commonly found in the left
scapular region. An external tumor is present in many cases, projecting
either through the upper part of the sternum or to the right, sometimes
involving the sternum and costal cartilages on both sides, forming a tumor
the size of a cocoa-nut or even larger. The skin is thin, often blood-
stained, or it may have ruptured, exposing the laminae of the sac. The
apex beat may be much dislocated, particularly when the sac is large. It
is more commonly a dislocation from pressure than from enlargement of
the heart itself.
Palpation. — The area and degree of pulsation are best determined by
palpation. When the aneurism is deep-seated and not apparent exter-
nally, the bimanual method should be used, one hand upon the spine and
the otlier on the sternum. When the sac has perforated the chest wall
the impulse is, as a rule, forcible, slow, heaving, and expansile. The re-
Histanco may be very great if there are thick laminae beneath the skin ;
674: DISEASES OF THE CIRCULATORY SYSTEM.
more rarely the sac is soft and fluctuating. The hand upon the sac, or
on the region in which it is in contact with the chest wall, feels in many-
cases a diastolic shock, often of great intensity, which forms one of the
valuable physical signs of aneurism. A systolic thrill is sometimes pres-
ent, not so often in saccular aneurisms as in the dilatation of the arch.
The pulsation may sometimes be felt in the suprasternal notch.
Percussion. — The small and deep-seated aneurisms are in this respect
negative. In the larger tumors, as soon as the sac reaches the chest wall,
there is produced an area of abnormal dulness, the position of which de-
pends upon the part of the aorta affected. Aneurisms of the ascending
arch grow forward and to the right, producing dulness on one side of the
manubrium ; those from the transverse arch produce dulness in the mid-
dle line, extending toward the left of the sternum, while aneurisms of
the descending portion most commonly produce dulness in the left inter-
scapular and scapular regions. The percussion note is flat and gives a
feeling of increased resistance.
Auscultation. — Adventitious sounds are not always to be heard. Even
in a large sac there may be no murmur. Much depends upon the thick-
ness of the laminae of fibrin. An important sign, particularly if heard
over a dull region, is a ringing, accentuated second sound, a phenomenon
rarely missed in large aneurisms of the aortic arch. A systolic murmur
may be present ; sometimes a double murmur, in which case the diastolic
hritit is usually due to associated aortic insufficiency. The systolic mur-
mur alone is of little moment in the diagnosis of an aneurismal sac. With
the single stethoscope the shock of the impulse with the first sound is
sometimes very marked.
Among other physical signs of importance are slowing of the pulse in
the arteries beyond the aneurism, or in those involved in the sac. There
may, for instance, be a marked difference between the right and left radial,
both in volume and time. A physical sign of large thoracic aneurism
which I have not seen referred to is obliteration of the pulse in the ab-
dominal aorta and its branches. My attention was called to this in a
patient who was stated to have aortic insufficiency. There was a well-
marked diastolic murmur, but in the femorals and in the aorta I was
surprised to find no trace of pulsation, and not the slightest throbbing in
the abdominal aorta or in the peripheral arteries of the leg. The circula-
tion was, however, unimpaired in them and there was no dilatation of the
veins. Attracted by this, I then made a careful examination of the pa-
tient's back, when the circumstance was discovered, which neither the
patient himself nor any of his physicians had noticed, that he had a very
large area of pulsation in the left scapular region. The sac probably
was large enough to act as a reservoir annihilating the ventricular systole,
and converting the intermittent into a continuous stream.
The tracheal tugging., a valuable sign in deep-seated aneurisms, was
described by Surgeon-Major Porter, and has been specially studied by my
ANEURISM. 675
colleagues Ross and MacDonncll * at tlie Montreal General Hospital. To
test it the patient should sit up with the head inclined forward, so as com-
pletely to relax the neck. The cricoid cartilage is grasped between the
index-finger and the thumb and by upward pressure the trachea put upon
the stretch. In healthy individuals no sensation is felt, but if an aneu-
rism is attached to it or is adherent in the immediate vicinity, the stretch-
ing is accompanied by a well-marked and characteristic tugging. On
several occasions I have known this to be a sign of great value in the
diagnosis of deep-seated aneurisms. I have never felt it in tumors, or in
the extreme dynamic dilatation of aortic insuffi<3iency.
Occasionally a systolic murmur may be heard in the trachea, as pointed
out by David Drummond, or even at the patient's mouth, when opened.
This is either the sound conveyed from the sac, or is produced by the air
as it is driven out of the wind-pipe during the systole.
An important but variable feature in thoracic aneurism is jpain^ which
is particularly marked in deep-seated tumors. It is usually paroxysmal,
sharp, and lancinating, often very severe when the tumor is eroding the
vertebrae, or perforating the chest wall. In the latter case, after perfora-
tion the pain may cease. Anginal attacks are not uncommon, particularly
in aneurisms at the root of the aorta. Frequently the pain radiates down
the left arm or up the neck, sometimes along the upper intercostal nerves.
Cough results either from the direct pressure on the wind-pipe, or is as-
sociated with bronchitis. The expectoration in these instances is abundant,
thin, and watery ; subsequently it becomes thick and turbid. Paroxysmal
cough of a peculiar brazen, ringing character is a characteristic symptom
in some cases, particularly when there is pressure on the recurrent laryn-
geal nerves.
Dyspnma^ which is common in cases of aneurism of the transverse
portion, is not necessarily associated with pressure on the recurrent laryn-
geal nerves, but may be due directly to compression of the trachea or the
left bronchus. It may occur with marked stridor. Loss of voice and
hoarseness are consequences of pressure on the recurrent laryngeal, usually
the left, inducing either a spasm in the muscles of the left vocal cord or
paralysis.
Paralysis of an abductor on one side may be present without any
symptoms. It is more particularly, as Semon states, when the paralytic
contractures supervene that the attention is called to laryngeal symptoms.
Hcemorrhafje in thoracic aneurism may come from {a) the soft granula-
tions in the trachea at the point of compression, in which case the sputa are
blood-tinged, but large quantities of blood are not lost ; {h) from rupture
of the sac into the trachea or bronchi ; (c) from perforation into the lung
or erosion of the lung tissue. The bleeding may be profuse, rapidly prov-
ing fatal, and is a common cause of death. It may persist for weeks or
* London Lancet, 1891.
C76 DISEASES OF THE CIRCULATORY SYSTEM.
months, in which case it is simply haemorrhagic weeping through the sac,
wliicli is exposed in the trachea. In some instances, even after a very
profuse haemorrhage, the patient recovers and may live for years. A pa-
tient wuth well-marked thoracic aneurism, whom I showed to my class at
tlie University of Pennsylvania four years ago and who had had several
brisk haimorrhages, died recently, hi^ving in the mean time enjoyed aver-
age health.
Difficulty of swallowing is a comparatively rare symptom, and may be
due either to spasm or to direct compression. The sound should never
be passed in these cases, as the oesophagus may be almost eroded and a
perforation may be made.
Among other signs and symptoms venous compression, which has
already been mentioned, may involve one subclavian or the superior vena
cava. A curious phenomenon in intrathoracic aneurism is the clubbing
of the fingers and incurving of the nails of one hand, of which two ex-
amples have been under my care, in both without any special distention
or signs of venous engorgement. Tumors of the arch may involve the
pulmonary artery, producing compression, or in some instances adhesion
of the pulmonary segments and insufficiency of the valve ; or the sac may
rupture into the artery, an accident which happened in two of my cases,
producing instantaneous death.
Pressure on the sympathetic is particularly liable to occur in growths
from the ascending portion of the arch. Either the upper dorsal or the
lower cervical ganglion is involved. The symptoms are variable. If the
nerve is simply irritated tliere is stimulation of the vaso-dilator fibres and
dilatation of the pupil. AVith this may be associated pallor of the same
side of the face. On the other hand, destruction of the cilio-spinal
branches causes paralysis of the dilator fibres, in consequence of which
the iris contracts, the vessels on the side of the head dilate, causing con-
gestion, and in some instances unilateral SAveating. It is much more com-
mon to see the pupillary symptoms alone than in combination either with
pallor, redness, or sweating.
The clinical picture of aneurism of the aorta is extremely varied.
Many cases present characteristic symptoms and no physical signs, while
otliers have well-marked physical signs and no symptoms. As Broadbent
remarks, tlie aneurism of physical signs springs from the ascending por-
tion of the aorta ; the aneurism of symptoms grows from the transverse
arch.
Aneurism of the aorta may be confounded with : {a) The violent
thr()ljl)ing impulse of the arch in aortic insufficiency. I have already re-
ferred to a case of this kind in which the diagnosis of aneurism was made
by several good ol)servers. In a case recently under observation dulne^s
and pulsation existed in the second right interspace with a well-marked
systolic and a loud diastolic murmur, which was heard far out in the right
mammary region. The question arose whether aneurism was present in
ANEURISM. G77
addition to tlic aortic insufficiency. The post-mortem showed tlie mar-
gin of the riglit king retracted and adherent to the pericardium, leaving
exposed the aorta, which must have been greatly distended during each
systole.
(b) Siinple Dynamic Pulsation. — No instance of this, which is com-
mon in the abdominal aorta, has ever come under my notice. One which
came under the care of William Murray and Bramwell presented, without
any pain or pressure symptoms, pulsation and dulness over the aorta. The
condition gradually disappeared and was thought to be neurotic.
(c) Dislocation of the heart in curvature of the spine may cause great
displacement of the aorta, so that it has been known to pulsate forcibly
to the right of the sternum.
{d) Solid Tumors. — When the tumor projects externally and pulsates
the difficulty may be considerable. In tumor the heaving, expansile pul-
sation is absent, and there is not that sense of force and power which is so
striking in the throbbing of a perforated aneurism. There is not to be
felt as in aortic aneurism the shock of the heart-sounds, particularly the
diastolic shock. Auscultatory sounds are less definite, as large aneurisms
may occur without murmur ; and, on the other hand, murmurs may be
heard over tumors. The greatest difficulty is in the deep-seated thoracic
tumors, and here the diagnosis may be impossible. I hav^e already re-
ferred to the case which was regarded by Skoda as aneurism and by Op-
polzer as tumor. The j^hysical signs may be indefinite. The ringing
aortic second sound is of great importance and is rarely, if ever, heard
over tumor. Tracheal tugging is here a valuable sign. Pressure j)he-
nomena are less common in tumor, whereas pain is more frequent. The
general appearance of the patient in aneurism is much better than in
tumor. There may be signs of enlargement of the glands in the axilla or
in the neck. Healthy, strong males who have worked hard and have had
s}7)hilis are the most common subjects of aneurism. Occasionally cancer
of the oesophagus may simulate aneurism, producing pressure on the left
bronchus, and in one instance at the Philadelphia Hospital, with a husky,
brazen cough, the symptoms were very suggestive.
{e) Pulsating Pleurisy. — In cases of empyema necessitatis^ if the pro-
jecting tumor is in the neighborhood of the heart and pulsates, the condi-
tion may readily be mistaken for aneurism. The absence of the heaving,
firm distention and of the diastolic shock would, together with the his-
tory and the existence of pleural effusion, determine the nature of the case.
If necessary, puncture may be made with a fine hypodermic needle. In a
majority of the cases of pulsating pleurisy the throbbing is diffuse and
widespread, moving the whole side.
Prognosis. — The outlook in thoracic aneurism is always grave. Life
may be prolonged for some years, but the patients are in constant jeopardy.
Spontaneous cure is not very infrequent in the small sacculated tumors of
the ascending and thoracic portions. The cavity becomes filled with lam-
G78 DISEASES OF THE CIRCULATORY SYSTEM.
inae of firm fibrin, which become more and more dense and hard, the
sac shrinks considerably, and finally lime salts are deposited in the old
fibrin. The laminae of fibrin may be on a level with the lumen of the ves-
sel, causing complete obliteration of the sac. The cases which rupture ex-
ternally, as a rule run a rapid course, although to this there are exceptions ;
the sac may contract, become firm and hard, and the patient may live for
five, or even, as in a case mentioned by Balfour, for ten years. The cases
which have lasted longest in my experience have been those in which a
saccular aneurism has projected from the ascending arch. One patient in
Montreal had been known to have aneurism for eleven years. The aneu-
rism may be enormous, occupying a large area of the chest, and yet life be
prolonged for many years, as in the case mentioned as under the care of
Skoda and Oppolzer. One of the most remarkable instances is the case of
dissecting aneurism reported by Graham. The patient was invalided after
the Crimean AYar with aneurism of the aorta, and for years was under the
observation of J. H. Richardson, of Toronto, under whose care he died
In 1885. The autopsy showed a healed aneurism of the arch, with a dis-
secting aneurism passing the whole length of the aorta, which formed a
double tube.
Treatment. — In a large proportion of the cases this can only be pal-
liative. Still in every case measures should be taken which are known to
promote clotting and consolidation within the sac. In any large series
of cured aneurisms a considerable majority of the patients have not been
known to be subjects of the disease, but the obliterated sac has been found
accidentally at the post mortem.
The most satisfactory plan in early cases, when it can be carried out
thoroughly, is that advised by the late Mr. Tufnell, of Dublin, the essen-
tials of which are rest and a restricted diet. Rest is essential and should,
as far as possible, be absolute. The reduction of the daily number of
heart-beats when a patient is recumbent and makes no exertion whatever
amounts to many thousands, and is one of the principal advantages of
this plan. Mental quiet should also be enjoined. The diet advised by
Tufnell is extremely rigid — for breakfast, two ounces of bread and butter
and two ounces of milk ; for dinner, two or three ounces of meat and
three or four ounces of milk or claret ; for supper, two ounces of bread
and two ounces of milk. This low diet diminishes the blood-volume
and is thought also to render the blood more fibrinous. It reduces
greatly the blood-pressure within the sac, in this manner favoring coagu-
lation. This treatment should be pursued for several months, but, except
in persons of a good deal of mental stamina, it is impossible to carry it
out for more tlian a few weeks at a time. It is a form of treatment
adapted only for the saccular form of aneurism, and in cases of large sacs
communicating with the aorta by a comparatively small orifice the chances
of consolidation are fairly good. Unquestionably rest and the restriction
of the liquids are the important parts of the treatment, and a grecier
ANEURISM. 670
variety and quantity of food may bo allowed with advantage. If this plan
cannot be thoroughly carried out, the patient should at any rate be ad-
vised to live a very quiet life, moving about with deliberation and avoiding
all sudden mental or bodily excitement. The bowels should l)e kept regu-
lar, and constipation and straining should be carefully avoided. Of medi-
cines, iodide of potassium, as advised by Balfour, is of great value. It
may be given in doses of from ten to fifteen or twenty grains three times
a day. Larger doses are not necessary. The mode of action is not well
understood. It may act by increasing the secretions and so inspissating
the blood, by lowering the blood-pressure, or, as Balfour thinks, by causing
thickening and contraction of the sac. The most striking effect of the
iodide in my experience has been the relief of the pain. The evidence is
not conclusive that the syphilitic cases are more benefited than the non-
s}^hilitic. All these measures have little value unless the sac is of a suit-
able form and size. The large tumors with wide mouths communicating
with the ascending portion of the aorta may be treated on the most ap-
proved plans for months without the slightest influence other than reduc-
tion in the intensity of the throbbing. A patient with a tumor project-
ing into the right pleura remained on the most rigid Tufnell treatment
for more than one hundred days, during which time he also took iodide
of potassium faithfully. The pulsations were greatly reduced and the area
of dulness diminished, and we congratulated ourselves that the sac was
probably consolidating. Sudden death followed rupture into the pleura,
and the sac contained only fluid blood, not a shred of fibrin. In cases in
which the tumor is large, or in Avhich there seems to be very little prospect
of consolidation, it is perhaps better to advise a man to go on quietly with
his occupation, avoiding excitement and worry. Our profession has of-
fered many examples of good work thoroughly and conscientiously carried
out by men with aneurism of the aorta, who wisely, I think, as the late
Hilton Fagge, preferred to die in harness. Other measures to induce
coagulation in the sac are electricity, which has occasionally proved suc-
cessful ; the insertion of horse-hair, thin wire, or needles ; the injection of
an astringent liquid, such as perchloride of iron, into the sac. In a few
cases only these have been followed by cure. The fine silver wire pushed
through a hypodermic needle is probably the most satisfactory method,
and may be combined with electrolysis, the method known as Loreta's.
Kerr and Rosenstein, of San Francisco, have recently reported cases in
which cure was effected in this way.
Other Symptoms requiring Treatment. — Pressure on veins causing en-
gorgement, particularly of the head and arms, is sometimes promptly re-
lieved by free venesection, and at any time during the course of a thoracic
aneurism, if attacks of dyspnoea with lividity supervene, bleeding may be
resorted to with great benefit. It has the advantage also of promptly
checking the pain, for which symptom, as already mentioned, the iodide
of potassium often gives relief. In the final stages morphia is, as a
G80 DISEASES OF THE CIRCULATORY SYSTEM.
rule, necessary. Dyspnoea, if associated with cyanosis, is best relieved
by bleeding. Chloroform inhalations may be necessary. The question
sometimes comes up with reference to tracheotomy in these cases of urgent
dyspnoea. If it can be shown by laryngoscopic examination that it is due
to bilateral abductor paralysis the trachea may be opened, but this is ex-
tremely rare, and in nearly every instance the urgent dyspnoea is caused
by pressure about the bifurcation. When the sac appears externally and
grows large an ice-cap may be applied upon it, or a belladonna plaster to
allay the pain. In some instances an elastic support may be used with
advantage, and I saw a physician with an enormous external aneurism in
the right mammary region who for many months had obtained great
relief by the elastic support, passing over the shoulder and under the arm
of the opposite side.
Digitalis, ergot, aconite, and veratrum viride are rarely, if ever, of
service in thoracic aneurism.
Aj^eurism of the Abdominal Aorta.
The sac is most common in the neighborhood of the coeliac axis. It
is rare in comparison with thoracic aneurism. The tumor may be fusi-
form or sacculated, and it is sometimes multiple. Projecting backward, it
erodes the vertebrae and may cause numbness and tingling in the legs
and finally paraplegia, or it may pass into the thorax and burst into the
pleura. More commonly the sac is on the anterior wall and projects for-
ward as a definite tumor, which may be either in the middle line or a
little to the left. The tumor may be large and evident, or when high up
beneath the pillar of the diaphragm it may attain considerable size with-
out being very apparent on palpation.
The symptoms are chiefly pain, very often of a cardialgic nature,
passing round the sides or localized in the back, and gastric symptoms,
particularly vomiting. Ketardation of the pulse in the femoral is a very
common symptom.
Diagnosis and Physical Signs.— Inspection may show marked
pulsation in the epigastric region, sometimes a definite tumor. A thrill is
not uncommon. The pulsation is forcible, expansile, and sometimes double
when the sac is large and in contact with the pericardium. On palpation a
definite tumor can he felt. If large, there is some degree of dulness on per-
cussion which usually merges with that of the left lobe of the liver. On aus-
cultation, a systolic murmur is, as a rule, audible, and is sometimes best
heard at the back. A diastolic murmur is occasionally present, usually
very soft in quality. One of the commonest of clinical errors is to mis-
take a throbbing aorta for an aneurism. It is to be remembered that no
pulsation, however forcible, or the presence of a thrill or a systolic
murmur justifies the diagnosis of abdominal aneurism unless there is a
definite tumor which can he grasjicd and ichich has an expansile pidsa-
ANEURISM. 681
Hon. Attention to this rule will save many errors. The throbbing or
pulsating aorta is met with in all neurasthenic conditions, particularly in
women, and it is remarkable with what violence the epigastrium may be
driven out with each systole. In ansemia, particularly some instances of
traumatic anaimia, the throbbing may be very great. In the case of a
large, stout man with severe haemorrhages from a duodenal ulcer the
throbbing of the abdominal aorta not only shook violently the whole ab-
domen, but communicated a pulsation to the bed, the shock of which
was distinctly perceptible to any one sitting upon it. Very frequently
a tumor of the pylorus, of the pancreas, or of the left lobe of the liver is
lifted with each impulse of the aorta and may be confounded with aneu-
rism. The absence of the forcible expansile impulse and the examina-
tion in the knee-elbow position, in which tlie tumor, as a rule, falls for-
ward, and the pulsation is not then communicated, suffice for differentia-
tion.
The outlook in abdominal aneurism is bad. A few cases heal spon-
taneously. Death may result from [a) complete obliteration of the lumen
by clots ; {h) compression paraplegia ; (c) rupture either into the pleura,
retroperitoneal tissues, peritonaeum or the intestines, very commonly the
duodenum ; [d) by embolism of the superior mesenteric artery, producing
infarction of the intestines.
The treatment is such as already advised in thoracic aneurism. "When
the aneurism is low down pressure has been successfully applied in a case
by Murray, of Newcastle. It must be kept up for many hours under chlo-
roform. The plan is not without risk, as patients have died from bruising
and injury of the sac.
Aneurism of the Branches of the Abdominal Aorta.
The cmliac axis is itself not infrequently involved in aneurism of the
first portion of the abdominal aorta. Of its branches, the splenic artery is
occasionally the seat of aneurism. This rarely causes tumor large enough
to be felt ; sometimes, however, the tumor is of large size. I have reported
a case in a man, aged thirty, who had an illness of several months' dura-
tion, severe epigastric pain and vomiting, which led his physicians in New
York to diagnose gastric ulcer. There was a deep-seated tumor in the left
hypochondriac region, the dulness of which merged with that of the spleen.
There was no pulsation, but it was thought on one occasion that a hruit
was heard. The chief symptoms while under observation were vomiting,
severe epigastric pain, occasional haematemesis, and finally severe haemor-
rhage from the bowels. An aneurism of the splenic artery the size of a
cocoa-nut was situated between the stomach above and the transverse colon
below, and extended to the left as far as the level of the navel. The sac
contained densely laminated fibrin. It had perforated the colon. I have
twice seen small aneurisms on the splenic artery. Of thirty-nine instances
682 DISEASES OF THE CIRCULATORY SYSTEM.
of aneurism on the branches of the abdominal aorta collected by Lebert,
ten were of the splenic artery.
Aneurism of the hepatic artery is very rare, and there are only ten or
twelve cases on record. The symptoms are extremely indefinite ; the con-
dition could rarely be diagnosed. In the case reported by Ross and
myself, a man aged twenty-one had the symptoms of pyaemia. The liver
was greatly enlarged, weighed nearly 5,000 grammes, and presented innu-
merable small abscesses. An oval aneurism, half the size of a small lemon,
involved the right and part of the left branches.
A few cases of aneurism of the superior mesenteric artery are on record.
The diagnosis is scarcely possible. Plugging of the branches or of the main
stem may cause the symptoms of infarction of the bowels which have al-
ready been considered.
Small aneurisms of the renal artery are not very uncommon. Large
tumors are rare. The sac may rupture and give rise to extensive retro-
peritoneal haemorrhage.
Arterio-venous Aneurism.
In this form there is abnormal communication between an artery and
a vein. When a tumor lies between the two it is known as varicose aneu-
rism ; when there is a direct communication Avithout tumor the vein is
chiefly distended and the condition is known as aneurismal varix.
An aneurism of the ascending portion of the arch may open directly
into the vena cava. Twenty-nine cases of this lesion have been analyzed
by Pepper and Griffith. Cyanosis, oedema, and great distention of the
veins of the upper part of the body are the most frequent symptoms, and
develop, as a rule, with suddenness. Of the physical signs a thrill is pres-
ent in some cases. A continuous murmur with systolic intensification is
of great diagnostic value. In a recent case, after the existence for some
time of pressure symptoms, intense cyanosis developed with engorgement
of the veins of the head and arms. Over the aortic region there was a
loud continuous murmur with systolic intensification.
A majority of the cases of arterio-venous aneurism and of aneurismal
varix result from the accidental opening of an artery and vein as in vene-
section, and are met with at the bend of the elbow or sometimes in the
temporal region. The condition may persist for years without causing
any trouble. Pulsation, a loud thrill, and a continuous humming mur-
mur are usually present.
Congenital Aneurism.
In consequence of failure of proper development of the elastic coat in
many places in tlie arterial system, multiple aneurisms may develop. In
the well-known case described by Kiissmaul and Maier, upon many of the
ANEURISM. 683
medium-sized arteries there were nodulixr prominences, which consisted of
thickening of the intima and infiltration of the adventitia and of the
media, with a nuclear growth which in places looked quite sarcomatous.
They called it a case of periarteritis nodosa^ and Eppinger holds that it
belongs to the category which he makes of congenital aneurism. As
many as sixty-three aneurismal tumoES have been found in one case. In
the smaller branches, such as the coronary and the mesenteric arteries or
in the pulmonary arteries, there may be numerous elongated or saccular
aneurisms varying in size from a cherry to a hazel-nut. These are true
aneurismal dilatations, and, according to Eppinger's careful study, consist
of the intima and the adventitia, the elastic lamina having disappeared.
The condition has been met with in children. Some of the cases, how-
ever, have been in adults ; but the term as applied by Eppinger ex-
presses, and probably correctly, the deep-seated fundamental error in
development which must be at the basis of this condition. The coronary
arteries is a favorite situation ; a case has been reported by Gee in a boy
of seven.
44
SECTION VI.
DISEASES OF THE BLOOD AND DUCTLESS
GLANDS.
I. an.€:mia.
Anemia may be defined as a reduction in the amount of the blood as
a whole or of its corpuscles, or of certain of its more important constitu-
ents, such as albumen and haemoglobin. The condition may be general
or local. The former alone we are here considering. It is interesting
to note, however, that the pallor, particularly of the face, which is one
of the most striking symptoms of ana3mia, is just as characteristic of local
anasmia due to fright or to nausea. There are persons persistently pale
without actual anaemia in whom the condition may be due to inherited
peculiarities.
Our knowledge is not yet sufficiently advanced to classify satisfactorily
the various forms of anaemia. The following provisional grouping may
be made : (1) Secondary or symptomatic anaemia; (2) primary, essential,
or cytogenic anaemia.
Secondary An.^mia.
Under this division comes a large proportion of all cases. The follow-
ing are the most important groups, based on the etiology :
(1) Ancemia from lionmorrliage^ either traumatic or spontaneous. The
loss of blood may be rapid, as in lesions of large vessels, in injury or in
rupture of aneurisms, or in cases of ulcer of the stomach or duodenum,
or post-partum haemorrhage. If the loss is excessive, death results from
lowering of the arterial pressure. In sudden profuse haemorrhage the
loss of three or four pounds of blood may prove fatal. In the rupture of
an aneurism into the pleura the loss of blood may amount to seven pounds
and a half, the largest quantity I have known to be shed into one cavity.
In a case of haematemesis the patient lost over ten pounds by measure-
ment in one week and yet recovered from the immediate effects. Even
after very severe haemorrhage the number of red blood-corpuscles is not
reduced so greatly as in forms of idiopathic anaemia. Thus in a case just
AN^^]MIA.
685
mentioned, at the termination of the week of bleeding there were nearly
1,390,000 red blood-eor})uscles to the eubic millimetre. 'J'he proeeHS of
regeneration goes on with great rapidity, and in some " bleeders " a week
or ten days suffice to re-establish the normal amount. The watery and
saline constituents of the blood are readily restored by absorption from
the gastro-intestinal tract. The albuminous elements also are quickly re-
newed, but it may take weeks or months for the corpuscles to reach the
APRIL. 1 MAY. JUNE.
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V
MEAN NORM.
NUMBER OF
WHITE
CORPUSCLES
BLACK, RED CORPUSCLES. RED, HAEMAGLOBIN, BLUE, COLOBLES8 CORPUSCLES.
Chart XVT. — Ilhistrates the rapidity with which anapinia is produced in purpura hae-
raorrhagica and the gradual recovery.*
normal standard. The accompanying chart illustrates the rapid fall and
gradual restitution in a case of severe purpura haemorrhagica.
The microscopical characters of the blood after severe haemorrhage are
not much changed ; the white corpuscles are relatively increased, pro-
ducing a condition of leucocytosis. Nucleated red corpuscles are present,
though usually not numerous. In the regeneration of the blood the de-
* On September 27th the patient returned from the country, where she had spent
the summer. The blood count was I lien: Red corpuscles, r),;}50.000 ; white corpus-
cles, 5,500; hjjcmoglobin, ninety-four per cent.
680 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
velopment of the lia3moglobin does not keep pace with that of the
corpuscles.
(2) Anaemia is frequently produced by long-continued drain on the
albuminous materials of the blood, as in chronic suppuration and Ikight's
disease. Prolonged lactation acts in the same way. liapidly growing
tumors may cause a profound anaemia, as in gastric cancer. The char-
acter of the blood in these cases is similar to that in anaemia after haemor-
rhage.
(3) Ancemia from Inanition. — This maybe brought about by defective
food supply, or by conditions which interfere with the proper reception
and preparation of the food, as in cancer of the oesophagus and chronic
dyspepsia. The reduction of the blood mass may be extreme, but the
plasma suffers proportionately more than the corpuscles, which, even in
the wasting of cancer of the oesophagus, may not be reduced more than
one half or three fourths.
(4) Toxic ancBtniay induced by the action of certain poisons on the
blood, such as lead, mercury, and arsenic, among inorganic substances,
and the virus of syphilis and malaria among organic poisons. They act
either by directly destroying the red blood-corpuscles, as in malaria, or by
increasing the rate of ordinary consumption. The anaemia of pyrexia
may in part be due to a toxic action, but is also caused in part by the
disturbance of digestion and interference with the function of the blood-
making organs.
Primary ok Essential Anemia.
1. Chlorosis. — An essential anaemia met with chiefly in young girls,
characterized by a marked relative diminution of the haemoglobin.
Etiology. — Cases are rarely seen in men. Blondes are more fre-
quently affected than brunettes. The age of onset is usually between the
fourteenth and the seventeenth years. Recurrences throughout the third
decade are, however, not uncommon. Chlorosis is extremely rare in
young children.
Hereditary influences probably })lay a part. Virchow pointed out that
in many cases there was a defective develoi)ment of the circulatory sys-
tem, either congenital or resulting in a failure of the normal rate of
growth. In some instances a compensatory hypertrophy of the heart
has been found.
The disease is most common among the ill-fed, overworked girls of
large towns, who are confined all day in close, badly-lighted rooms, or
have to do much stair-climbing. Cases are frequent, however, under the
most favorable conditions of life. Lack of proper exercise and fresh air,
and improper food are important factors. Emotional and nervous dis-
turbances may be j^rominent, so prominent that certain writers have
regarded the disease as a neurosis. Menstrual disturbances are not un-
AN^^]MIA. 687
common, but are probably a, sequence, not a cause of chlorosis. Sir
Andrew Clark believes tliat constipation plays an important ro/e, and that
the condition is in reality a coprwinia due to the absorption of poisons —
leucomaines and ptomaines — from the- large bowel.
Morbid Anatomy. — Fortunately the disease is rarely fatal. 'J'he
fat is well retained. Hypoplasia of the aorta and larger arteries has been
found in some cases, and the vessels have had a remarkable degree of elas-
ticity. The heart is usually dilated and the left ventricle hypertrophied.
Hypoplasia of the uterus and defective development of the genitalia have
also been found.
Symptoms. — The blood examination : Johann Duncan in 1867 first
called attention to the fact that the essential feature was not a quan-
titative but a qualitative change in the haemoglobin. This has been
abundantly confirmed. The red blood-corpuscles may show only a moder-
ate grade of reduction, but the corpuscles themselves are very poor in
haemoglobin. Thus in forty consecutive cases examined at my clinic by
Thayer, the average number per cubic millimetre of the red blood-corpus-
cles was 4,225,181, or over eighty per cent, whereas the percentage of haemo-
globin for the total number was 44-1 per cent. The accompanying chart
illustrates w^ell these striking differences. The least blood-count in the
series of cases referred to above was 1,932,000. There may be all the physi-
cal characteristics and symptoms of a profound anaemia with blood-corpus-
cles nearly at the normal standard. Thus in one instance the globular rich-
ness was over eighty-five per cent with the haemoglobin about thirty-five.
These characteristics are distinctive, I believe, and not found in the same
grade in any other form of anaemia. The importance of the reduction in
the haemoglobin depends upon the fact that it is the iron-containing
element of the blood w^ith which in respiration the oxygen enters into
combination. This marked diminution in the iron has also been deter-
mined by chemical analysis of the blood. The microscopical character-
istics of the blood are as follows : In severe cases the corpuscles may be
extremely irregular in size — poikilocytosis — which may occasionally be as
marked as in pernicious anaemia. The large forms of red blood-cells are
common, but the average size is stated to be below normal. The color of
the corpuscles is noticeably pale and the deficiency may be seen either in
individual corpuscles or in the blood mixture prepared for counting. The
leucocytes may show a slight increase ; thus, the average of the forty cases
above referred to was 8,256 per cubic millimetre.
The gcmeral symptoms of chlorosis are those of an anaemia of moderate
grade. The subcutaneous fat is well retained or even increased in amount,
'i'he complexion is peculiar ; neither the blanched aspect of haemorrhage
nor the muddy pallor of grave anaemia, but a curious yellow-green tinge
whicli has given the name to the disease, and to its popular designation,
the green sickness. In cases of moderate grade the color may be decep-
tive, as the clieeks have a reddish tint, particularly on (jxertion (chlorosis
688
DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
rubra). The subjects complain of breathlessness and palpitation, and
there may be a tendency to fainting. The palpitation and breathlessness
JANUARY. i FEBRUARY. | MARCH. |
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BLACK, RED CORPUSCLES.
RED. HAEMAGLOBIN.
Chart XVII.— Chlorosis,
MEAN NORM.
NUMBER OF
WHITE
CORPUSCLES
BLUE, COLORLESS CORPUSCLES.
often lead to the suspicion of heart or lung disease. The eyes have a
peculiar brilliancy and the sclerotics are of a sky-blue color Occasionally
the skin shows areas of pigmentation, particularly about the joints.
Digestive symptoms are common. The appetite is capricious and the
patients often have a longing for unusual articles, particularly acids. In
some instances they eat all sorts of indigestible things, such as chalk or
even earth. Constipation is a common symptom, and, as already men-
tioned, hjis l)een regarded as an important element in causing the disease.
Contourier has noted the frequent association of dilatation of the stomach
with chlorosis, and states that in some cases this may be an etiological
factor, while in otliers it may be a result.
The circulatory symptoms are imi)()rtant. Palpitation of the heart oc-
ANyEMIA. G89
curs on exertion, and may be the most distressing symptom of which the
patient complains. Percussion may show slight increase in the transverse
dulness. A systolic murmur is heard at the apex or at the base ; more
commonly at the latter, but in extrerae cases at both. A diastolic murmur
is rarely heard. The systolic murmur is usually loudest in the second left
intercostal space, where there is sometimes a distinct pulsation. The
exact mode of production is still in dispute. Balfour holds that it is pro-
duced at the mitral orifice by relative insufficiency of the valves in the
dilated condition of the ventricle. On the right side of the neck over the
jugular vein a continuous murmur is heard, the hruit de diahle^ or hum-
ming-top murmur.
The pulse is usually full and soft. Pulsation in the peripheral veins is
sometimes seen. There is a tendency to thrombosis in the veins ; most
commonly in the femoral, but in other instances in the longitudinal sinus,
or the thrombosis may be multiple. Except in the sinuses, the condition
is rarely serious. Tuckwell has reported an instance in which there was
embolism of the right axillary artery with the loss of a thumb and part
of the fingers. Brayton Ball has recently called attention to the impor-
tance of this feature of chlorosis.
As in all forms of essential anaemia, fever is not uncommon. Especial
attention has of late been directed to this by French writers.* Chlorotic
patients suffer frequently from headache and neuralgia, which may be
paroxysmal. Hysterical manifestations are not infrequent. Menstrual
disturbances are very common — amenorrhoea or dysmenorrhoea. With
the improvement in the blood condition this function is usually restored.
Diagnosis. — The green sickness, as it is sometimes called, is in many
instances recognized at a glance. The well-nourished condition of the
girl, the peculiar complexion, which is most marked in brunettes, and the
white sclerotics are very characteristic. A special danger exists in mis-
taking the anaemia of the early stage of pulmonary tuberculosis for chlo-
rosis. The palpitation of the heart and shortness of breath frequently
suggest heart-disease, and the cedema of the feet and general pallor cause
the cases to be mistaken for Bright's disease. In the great majority of
cases the characters of the blood readily separate chlorosis from other
forms of anaemia.
2. Idiopathic or Progressive Pernicious Anaemia. — The disease was
first clearly described by Addison, who called it idiopathic anaemia.
Channing and Gusserow described the cases occurring post partum, but
to Biermer we ow^e a revival of interest in the subject.
Etiology. — The existence of a separate disease worthy of the term
progressive pernicious anaemia has been doubted, but there are unques-
tionably cases in which, as Addison says, there exist none of the usual
causes or concomitants of anaemia. Clinically there are several different
* Trazit, Paris Thesis, 1888.
690 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
groups wliich present the characters of a progressive and pernicious anae-
mia and are etiologically different. Thus, a fatal anaemia may be due to
the presence of parasites, or may follow haemorrhage, or be associated
witli clironic atrophy of the stomach ; but when we have excluded all
these causes there remains a group which, in the words of Addison, is
characterized by a "general anaemia occurring without any discoverable
cause whatever, cases in which there had been no previous loss of blood,
no exhausting diarrhoea, no chlorosis, no purpura, no renal, splenic, mias-
matic, glandular, strumous, or malignant disease."
Idiopathic anaemia is widely distributed. It is of frequent occurrence
in the Swiss Cantons, and is not uncommon in this country. It affects
middle-aged persons, but instances in children have been described. Grif-
fith mentions about ten cases occurring under twelve years of age. The
youngest patient I have seen was a girl of twenty. Males are more fre-
quently affected than females. Of my 27 cases, 10 were females and 17
were males. Of 110 cases collected by Coupland, 5G were in men and 54
in women.
With the following conditions may be associated a profound anaemia
not to be distinguished clinically from Addison's idiopathic form :
(a) Pregnancy and Parturition. — The symptoms may develop during
pregnancy, as in 19 of 29 cases of this group in Eichhorst's table. More
commonly, in my experience, the condition has been post partum ; thus,
of my 27 cases, 5 followed delivery.
{h) Atrophy of the Stomach. — This condition, early recognized by Flint
and Fenwick, may certainly cause a progressive pernicious anaemia. By
modern methods it may now be possible to exclude this extreme gastric
atrophy.
{c) Parasites. — The most severe form may be due to the presence of
parasites, and the accounts of cases depending upon the anchylostoma and
the bothriocephalus describe a progressive and often pernicious anaemia.
After the exclusion of these forms there remains a large proportion,
numbering eighteen cases in my series, which correspond to Addison's
description. The etiology of these cases is still dark. The researches of
Quincke and his student Peters showed that there was an enormous in-
crease in tlie iron in tlie liver, and he suggested that the affection was
probably due to increased haemolysis. This has been strongly supported
by the extensive observations of Hunter, who has also shown that the
urine excreted is darker in color and contains pathological urobilin. The
lemon tint of the skin or the actual jaundice is attributed, on this view,
to the changes in the liver cells produced by the excessive amount of pig-
ment, but in the light grades it is unquestionably ha3matogenous. To
explain the luDmolysis, it has been thought that in the condition of faulty
gastro-intestinal digestion, which is so commonly associated with these
cases, poisonous materials are developed, which when absorbed cause de-
struction of the corpuscles. Certainly the evidence for haemolysis is very
ANtEMIA. G91
strong, but we are still far away from a full knowledge of the eonditions
under which it is produced.
On the other hand, V. P. Henry, Stephen Mackenzie, and other au-
thorities incline to the belief that the essence of the disease is in defective
haemogenesis, in consequence of which the red blood-corpuscles are abnor-
mally vulnerable. A point noted by Copeman, that the haemoglobin crys-
tallizes from the blood-corpuscles with great readiness, can scarcely be
regarded as favoring the view of imperfect haemogenesis, since this is a
feature specially characteristic of the blood of the young.
Morbid Anatomy. — The body is rarely emaciated. A lemon tint
of the skin is present in a majority of the cases. The muscles often
are intensely red in color, like horse-flesh, while the fat is light yellow.
Haemorrhages are common on the skin and serous surfaces. The heart is
usually large, flabby, and empty. In one instance I obtained only two
drachms of blood from the right heart, and between three and four from
the left. The muscle substance of the heart is intensely fatty, and of a
pale, light-yellow color. In no affection do we see more extreme fatty
degeneration. The lungs show no special changes. The stomach in many
instances is normal, but in some cases of fatal anaemia the mucosa has
been extensively atrophied. In the case described by Henry and myself
the mucous membrane had a smooth, cuticular appearance, and there was
complete atrophy of the secreting tubules. The liver may be enlarged
and fatty. In most of my autopsies it was normal in size, but usu-
ally fatty. The iron is in excess, and in striking contrast to cases of
secondary anaemia. It is deposited in the outer and middle zones of the
lobules, and in two specimens which I examined seemed to have such a
distribution that the bile capillaries were distinctly outlined. This is
certainly, as Hunter states, a special and characteristic lesion, possibly
peculiar to pernicious anaemia. A. J. Scott examined for me the livers
in forty-five consecutive autopsies without finding (except in pernicious
anaemia) this special distribution of pigment.
The spleen shows no important changes. In one of Palmer Howard's
cases the organ weighed only an ounce and five drachms. The iron pig-
ment is usually in excess. The lymph glands may be of a deep red color.
The amount of iron pigment is increased in the kidneys, chiefly in the
convoluted tubules. The bone marrow, as pointed out by H. C. Wood,
may resemble that of a child. This observation has been repeatedly con-
firmed, but the condition does not appear to be constant. Changes in the
ganglion cells of the sympathetic have been reported on several occasions.
Lichtheim has found sclerosis in the posterior columns of the cord, which
he thinks secondary to the anaemia, and a similar change has been met
with in two recent cases by Morris Lewis and Burr.
Symptoms. — The patient may have been in previous good health,
but in many cases there is a history of gastro-intestinal disturbance, mental
shock, or worry. The description given by Addison presents the chief
G92 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
features of the disease in a masterly manner. " It makes its approach in
80 slow and insidious a manner that the patient can hardly fix a date to
the earliest feeling of that languor which is shortly to become so extreme.
The countenance gets pale, the whites of the eyes become pearly, the
general frame flabby rather than wasted, the pulse perhaps large, but
remarkably soft and compressible, and occasionally with a slight jerk,
especially under tlie slightest excitement. There is an increasing indis-
position to exertion, with an uncomfortable feeling of faintness or breath-
lessness in attempting it ; the heart is readily made to palpitate ; the whole
surface of the body presents a blanched, smooth, and waxy appearance ;
the lips, gums, and tongue seem bloodless, the flabbiness of the solids in-
creases, the appetite fails, extreme languor and faintness supervene,
breathlessness and palpitations are produced by the most trifling exertion
or emotion ; some slight oedema is probably perceived about the ankles ;
the debility becomes extreme — the patient can no longer rise from bed ;
the mind occasionally wanders ; he falls into a prostrate and half-torpid
state, and at length expires ; nevertheless, to the very last, and after a
sickness of several months' duration, the bulkiness of the general frame
and the amount of obesity often present a most striking contrast to the
failure and exhaustion observable in every other respect."
The Blood. — The corpuscles may sink to one fifth or less of the normal
number. They may sink to 500,000 per cubic millimetre, and in a case
of Quincke's the number was reduced to 143,000 per cubic millimetre.
The haemoglobin is relatively increased, so that the individual globular
richness is plus, a condition exactly the opposite to that which occurs in
chlorosis, in which the corpuscular richness in coloring matter is minus.
The relative increase in the haemoglobin is probably associated with the
average increase in the size of the red blood-corpuscles. The accompany-
ing chart illustrates these points. Microscopically the red blood -corpus-
cles present a great variation in size, and there can be seen large giant
forms, megalocytes, which are often ovoid in form, measuring eight, eleven,
or even fifteen micromillimetres in diameter, a circumstance which Henry
regards as indicating a reversion to a lower type. Laache thinks these
pathognomonic, and they certainly form a constant feature. There are
also small round cells, microcytes, from two to six micromillimetres in
diameter, and of a deep red color. The corpuscles show a remarkable
irregularity in form, elongated and rodlike or pyriform ; one end of a
corpuscle may retain its shape while the other is narrow and extended.
To this condition of irregularity Quincke gave the name poikilocytosis.
The leucocytes are generally diminislied in number, and the relative per-
centage of the mononuclear elements is somewhat liigher than in normal
blood.
Nucleated red blood-corpuscles are constantly present, as pointed out
by Ehrlich. Besides the ordinary form, which is of the same size as the
common corpuscle and which has a small, deeply stained nucleus (normo-
ANEMIA.
693
blasts), there are very large forms with large, palely staining nuclei (gigan-
toblasts), which resemble somewhat the larger megalocytes. Ehrlich re-
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MEAN NORM.
NUMBER OF
WHITE
CORPUSCLES
BLACK, RED CORPUSCLES.
RED, HAEMOGLOBIN.
Chart XVIII. — Pernicious anaemia.
BLUE, COLORLESS CORPUSCLES.
gards the presence of these as almost distinctive of progressive pernicious
anaemia ; they are only found here and in the later stages of leukaemia.
The bhjod-plates are either absent or very scanty.
The cardio-vascular symptoms are important and are noted in the de-
scription given above. Hgemic murmurs are constantly present. The
larger arteries pulsate visibly and the throbbing in them may be distress-
ing to the patient. The pulse is full and frcfjuently suggests the water-
hammer beat of aortic insufficiency. The ca])illary pulse is frequently to
be se(;n. The superficial veins are often prominent, and in two cases I
have seen well-marked pulsation in them. Haemorrhages may occur, either
694: DISEASES OP THE BLOOD AND DUCTLESS GLANDS.
in the skin or from the mucous surfaces. Retinal haemorrhages are com-
mon. There are rarely symptoms in the respiratory organs.
Gastro-intestinal symptoms, such as dyspepsia, nausea, and vomiting,
may be present throughout the disease. Diarrhoea is not infrequent. The
urine is usually of a low specific gravity and sometimes pale, but in other
instances it is of a deep sherry color, shown by Hunter and Mott to be
due to great excess of urobilin. Fever is a variable symptom. For weeks
at a time the temperature may be normal, and then irregular pyrexia may
develop. Nervous symptoms may occur, numbness and tingling, and oc-
casionally symptoms resembling those of tabes. Lepine reports a case of
extensive paralysis.
Diagnosis. — From chlorosis the disease is readily distinguished. I
have not seen a case in which the two diseases could have been con-
founded. Tavo points in the blood examination are of importance —
namely, the relative increase in the haemoglobin and the presence of the
large forms of nucleated red blood-corpuscles, the gigantoblasts of Ehr-
lich. Poikilocytosis may occur in any severe anaemia. The separation
of the different clinical forms above referred to can usually be made. The
profound secondary anaemia of cancer of the stomach may sometimes be
puzzling, but the skin is rarely, if ever, lemon-tinted, and the blood has
the characteristics of a secondary, not a primary anaemia.
Prognosis. — In the true Addisonian cases the outlook is bad, though
of late years on the arsenic treatment the proportion of recovery is increased.
My personal experience is as follows : Of the 27 cases 4 are now under ob-
servation, 2 of these having recovered with arsenic. Of the remaining 23
the following statement may be made : Four of the 5 post-partum cases
recovered, and when I left ^lontreal 3 of these cases had remained in good
health for several years. Of the remaining 18 cases 2 were lost sight of ;
1 had improved very much. The remaining 16 are dead. Six of these
fatal cases recovered from the first attack ; one had an interval of nearly
three years, and another nearly two years, before the return. I know of
no instance in a male in which the recovery has lasted for five years. In
Pye-Smith's article in Guy's Hospital Reports, he mentions twenty cases
of recovery. Hale White, in a recent article, states that one of these
cases, treated by arsenic in 1880, remained alive and well January, 1801.
One of my patients made an apparently complete recovery and resumed
active business and political duties. So .characteristic are recurrences in
this affection that Stephen Mackenzie, in his recent lectures, considered
them under a separate heading of relapsing pernicious anaemia.
Treatment of Anaemia. — Secondary Anmmia. — The traumatic
cases do best, and witli plenty of good food and fresh air the blood
is readily restored. The extraordinary rapidity with which the normal
percentage of red blood-corpuscles is reached without any medication
whatever is an impoi-tant lesson. The cause of the haemorrhage should be
sought and the necessary indications met. The large grouj) depending
AN^.MIA. 695
on the drain on the albuminous materials of the blood, as in Bright's
disease, suppuration, and fever, is difficult to treat successfully, and so long
as the cause keeps up it is impossible to restore the normal blood con-
dition. The anaemia of inanition requires plenty of nourishing food.
When dependent on organic changes in the gastro-intestinal mucosa not
much can be expected from either food or medicine. In the toxic cases
due to mercury and lead, the poison must be eliminated and a nutritious
diet given with full doses of iron. In a great majority of these cases
there is deficient blood formation, and the indications are briefly three —
plenty of food, an open-air life, and iron. As a rule it makes but little
difference what form of the drug is administered.
The treatment of chlorosis affords one of the most brilliant instances —
of which we have but three or four — of the specific action of a remedy.
Apart from the action of quinine in malarial fever, and of mercury and
iodide of potassium in syphilis, there is no other remedy the beneficial
effects of which we can trace w^ith the accuracy of a scientific experiment.
It is a minor matter liow the iron cures chlorosis. In a week we give to a case
as much iron as is contained in the entire blood, as even in the worst case
of chlorosis there is rarely more than a deficit of two grammes of this metal.
Iron is present in the faeces of chlorotic patients before they are placed
upon any treatment, so that the disease does not result from any deficiency
of available iron in the food. Bunge believes that it is the sulphur which
interferes with the digestion and assimilation of this natural iron. The
sulphides are produced in the process of fermentation and decomposition
in the faeces, and interfere with* the assimilation of the normal iron con-
tained in the food. By the administration of an inorganic preparation of
iron with which these sulphides combine the natural organic combinations
in the food are spared. In studying a number of charts of chlorosis it is
seen that there is an increase in the red blood-corpuscles under the infiu-
ence of the iron, and in some instances the globular richness rises above
normal. The increase in the haemoglobin is slower and the maximum
percentage may not be reached for a long time. I have for years in the
treatment of chlorosis used with the greatest success Blaud's pills, made
and given according to the formula in Niemeyer's text-book, in which
each pill contains 2 grs. of the sulphate of iron. During the first week one
pill is given three times a day. In the second week, two pills ; in the third
week, three pills, three times a day. This dose should be continued for
four or five weeks, at least, before reduction. An important feature in the
treatment of chlorosis is to persist in the use of the iron for at least three
months, and if necessary subsequently to resume it in smaller doses, as re-
currences are so common. The diet should consist of good, easily digested
food. Special care should be directed to the bowels, and if constipation is
present a saline purge should be given each morning. Such stress does
Sir Andrew Clark lay on the importance of constipation in chlorosis that
he states that if limited to the choice of one drug in the treatment of the
696 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
disease lie would choose a purgative. Dilute hydrochloric acid, manganese,
phosphorus, and oxygen have been recommended.
Treatment of Pernicious Anmmia. — Since the introduction by Byrom
Bramwell of arsenic in tliis affection a large number of cases have been
temporarily, a few permanently, cured by it. It should be given as Fowler's
solution in increasing doses. It is usually well borne, and patients, as a
rule, take up to twenty minims three times a day without any disturbance.
I usually begin with three minims and increase to five at the end of the
first week, to ten at the end of the second week, to fifteen at the end of
the third week, and, if necessary, increase to twenty or twenty-five. In a
case in which the recovery persisted for nearly three years, the dose was
gradually increased to thirty minims. These patients seem to bear the
arsenic extremely well. It is sometimes better borne as arsenious acid in
pill form. Vomiting and diarrhoea are rare ; occasionally puffiness of the
face is produced, and in some cases pigmentation of the skin.
Eest in bed and a light but nutritious diet (giving the food in small
amounts and at fixed intervals) are the first indications. I always prefer
to begin the treatment of a case of pernicious anasmia, whatever the grade
may be, with rest in bed as one of the essential elements. Massage will
also be found very beneficial. I have abandoned the use of rectal injec-
tions of dried blood. Iron seems to have no action in this form, but in
a case in which the arsenic disagrees it may be tried.
II. LEUKyCMIA.
Definition. — An affection characterized by persistent increase in the
white blood-corpuscles, associated with enlargement, either alone or to-
gether, of the spleen, lymphatic glands, or bone marrow.
The disease was described almost simultaneously by Virchow and by
Bennett, who gave to it the name leucocythsemia.
Etiology. — We know nothing of the conditions under which the
disease develops. It is not uncommon on this continent. Of 17 cases of
which I have notes, 11 occurred in Montreal, 2 in Philadelphia, and 4
within the past two years at the Johns Hopkins Hospital. It does not
seem more frequent in the southern parts of the country.
The disease is most common in the middle period of life. The young-
est of my cases was a child of eight months, and cases are on record of
the disease as early as the eighth or tenth week. It may occur as late as
the seventieth year. Males are more prone to the affection than females.
Of my cases 11 were in males and G in females. ]3irch-IIirschfeld states
that of 200 cases collected from the literature, 135 were males and 65
females.
A tendency to hoemorrhage has been noted in many cases, and some
of the patients have suffered repeatedly from nose-bleeding. In women
LEUKTI^^MIA. 697
the disease is most common at the climacteric. There are instances in
which it has developed during pregnancy. The case described by J.
Chalmers Cameron, of Montreal, is in this respect remarkable, as the pa-
tient passed through three pregnancies, bearing on each occasion non-
leukaemic children. The case is interesting, too, as showing the heredi-
tary character of the affection, as the grandmother and mother, as well
as a brother, suffered from symptoms strongly suggestive of leukaemia.
One of the patient's children had leukaemia before the mother showed any
signs, and a second died of the disease. At the last report this patient
had gradually recovered from the third confinement and the red blood-
corpuscles had risen to 4,000,000 per cubic millimetre, and the ratio of
white to red 1 to 200. Sanger has reported a case in which a healthy
mother bore a leukaemic child.
Malaria is believed by some to be an etiological factor. Of 150 cases
analyzed by Gowers, there was a history of malaria in 30 ; in my series
there was a history in at least 7. Syphilis appears in some cases to have
been closely associated with the disease. The disease has followed injury
or a blow.
The lower animals are subject to the affection, and cases have been
described in horses, dogs, oxen, cats, swine, and mice.
Morbid Anatomy. — The wasting may be extreme, and dropsy is
sometimes present. There is in many cases a remarkable condition of
polyaemia ; the heart and veins are distended with large blood-clots. In
Case XI of my series the weight of blood in the heart chambers alone
was 620 grammes. There may be remarkable distention of the portal,
cerebral, pulmonary, and subcutaneous veins. The blood is usually clotted,
and the enormous increase in the leucocytes gives a pus-like appearance
to the coagula, so that it has happened more than once, as in Virchow's
memorable case, that on opening the right auricle the observer at first
thought he had cut into an abscess. The coagula have a peculiar greenish
color, somewhat like the fat of a turtle. The alkalinity of the blood
is diminished. The fibrin is increased. The character of the corpus-
cles will be described under the symptoms. Charcot's octohedral crystals
separate from the blood after death. The specific gravity of the blood is
somewhat lowered. There may be pericardial ecchymoses.
The spleen in the great majority of cases is enlarged. Strong adhe-
sions may unite it to the abdominal wall, the diaphragm, or the stomach.
The capsule may be thickened. The vessels at the hilus are enlarged ;
the weight may range from two to eighteen pounds. The organ is in a
condition of chronic hyperplasia. It cuts with resistance, has a uniformly
red dish -brown color, and the Malpighian bodies are invisible. Grayish-
white, circumscribed, lymphoid tumors may occur throughout the organ,
contrasting strongly with the reddish-brown matrix. In the early stage
the swollen spleen pulp is softer, and it is stated that rupture has occurred
from the intense hyperaimia. Enlargement of the lymphatic glands may
698 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
occur, either in conjunction with splenic enlargement or alone. In only
one of my cases was the enlargement notable. In the cases of lymphatic
leuknemia the cervical, axillary, mesenteric, and inguinal groups may be
much enlarged, but the glands are usually soft, isolated, and movable.
They may vary considerably in size during the course of the disease. The
tonsils and the lymph follicles of the tongue, pharynx, and mouth may
be enlarged.
In tlie majority of cases the bone marrow is involved with the spleen,
the lieno-medullary form of the Germans. The marrow may be involved
alone, forming a pure myelogenous leukaemia. Instead of a fatty marrow,
the medulla of the long bones may resemble the consistent matter which
forms the core of an abscess, or it may be dark brown in color. In Pon-
fick's case there were hsemorrhagic infarctions. There may be much ex-
pansion of the shell of bone and localized swellings which are tender and
may even yield to firm pressure. Histologically, there are found in the
medulla large numbers of nucleated red corpuscles in all stages of develop-
ment, numerous cells with eosinophilic granules, and also many cells cor-
responding to the myelocytes found in the blood. Large mononuclear cells
in the process of division by karyokinesis may be abundant. Polynuclear
leucocytes are also present, as well as a certain number of small mononu-
clear elements.
The thymus is rarely involved, though it has been enlarged in some
of the cases of acute lymphatic leukaemia.
In a few instances there have been leukagmic enlargements in the
solitary and agminated glands of Peyer. In a case of AVillcocks there
were growths on the surface of the stomach and gastro-splenic omentum.
The liver may be enlarged, and in a case described by Welch it
weighed over thirteen pounds. The enlargement is usually due to a
diffuse leuksemic infiltration. The columns of liver cells are widely
separated by leucocytes, which are partly within and partly outside the
lobular capillaries. There may be definite leukaemic growths.
There are rarely changes of importance in the lungs. The kidneys
are often enlarged and pale, the capillaries may be distended with leu-
cocytes, and leukaemic tumors may occur. The skin may be involved, as
in a case described by Kaposi.
Leukaemic tumors in the organs are not common. They were present
in only one of the twelve autopsies in my series. In 159 cases collected
by Gowers there were only thirteen instances of leukemic nodules in the
liver and ten in the kidneys. These new growths probably develop from
leucocytes which leave the capillaries. Bizzozero has shown that the cells
which compose them are in active fission.
Symptoms. — The onset is insidious, and, as a rule, the patient
seeks advice for progressive enlargement of the abdomen and shortness
of breatli, or for the enlarged glands or the pallor, palpitation, and other
symptoms of anaemia. Bleeding at the nose is common. G astro-intestinal
liEVKJEMlA. C90
symptoms may precede the onset. Occasionally the first symptoms arc of
a very serious nature. In one of the cases of my series the boy played
lacrosse two days before the onset of the final haymatemesis, and in another
case, a girl who had, it was supposed, only a slight chlorosis, died of fatal
haemorrhage from the stomach before any suspicion had been aroused as
to the true condition.
Blood. — In all forms of the disease the diagnosis must be made by the
examination of the blood, as it alone offers distinctive features. In the
normal blood Ehrlich recognizes the following varieties of colorless ele-
ments : (a) Lymphocytes — small cells about the size of a red blood-
corpuscle, and probably derived from the lymphatic glands, which have
a single large, round, deeply staining nucleus, surrounded by, a narrow
rim of non-granular protoplasm. (b) Large mononuclear leucocytes —
cells several times as large as the red blood-corpuscle, with an oval or
elliptical nucleus and a relatively larger amount of ungranulated proto-
plasm, (c) Transitional forms — cells which resemble the last variety,
but have indentations and irregularities in the nucleus, (d) Polynuclear
leucocytes — these are about the same size or a little smaller than the last
variety. The nucleus is a long, deeply staining body which is bent and
twisted on itself into irregular shapes. The protoplasm of these cells is
filled with granules, which are stained, not by acid or basic coloring mat-
ters alone, but also by a combined fluid. The granules are therefore
termed neutrophilic, and the name " neutrophiles " is given to these cells.
(e) Cells about the same size as the last, but containing large, highly
refractile, fat-like granules, which have an aihnity for acid coloring mat-
ters. On account of their affmity for eosin, Ehrlich terms them eosino-
pliiles. In normal blood these cells occur in a definite proportion to each
other ; the lymphocytes fifteen to thirty per cent, the polynuclear sixty-
five to eighty per cent, the mononuclear and transitional forms about six
per cent, and the eosinophiles two to four per cent.
The most striking change in the more common form, the lieno-
myelogenic, is the increase in the colorless corpuscles. The average num-
ber of white per cubic millimetre is estimated at about 6,000 ; thus the pro-
portion of white to red is 1 to 500 — 1,000. In leukaemia the proportion
may be 1 to 10, or 1 to 5, or the ratio may reach 1 to 1. There are in-
stances on record in which the number of leucocytes has exceeded that of
the red corpuscles.
The character of the cells in splenic myelogenous leukagmia is as
follows: The lymphocytes are little, if at all, increased ; relatively they
are greatly diminished. The eosinophiles are present in normal or in-
creased relative proportion, so that there is a great total increase, and
their presence is a striking feature in the stained blood-slide. Tlie poly-
nuclear neutrophiles may be in normal proportion; more frequently they
are relatively diminished, and in the latter stages they may form but a
small proportion of the colorless elements. The most characteristic feature
700 DISEASES OP THE BLOOD AND DUCTLESS GLANDS.
of the blood in this form of leukaemia is the presence of cells which do
not occur in normal blood. They appear to be derived from the marrow,
and are called by Ehrlich myelocytes. They are as large or even larger
than the large mononuclear leucocytes, and are similar to them in ap-
pearance, but differ from them in the fact that the protoplasm is filled
with the fine neutrophilic granules: Miiller has recently found many
large mononuclear elements with karyokinetic figures in leukaemic blood
and in the marrow.
Nucleated red blood-corpuscles are present, usually in considerable
numbers. There is, as a rule, only a moderate reduction in the number
of red blood-corpuscles, rarely under two million per cubic millimetre.
The haemoglobin is usually reduced in a somewhat greater proportion.
The accompanying blood chart is from a case of leukaemia with an enor-
mously enlarged spleen.
The histological characters of the blood in acute lymphatic leukaemia
differ materially. The increase in the colorless elements is never so great
as in the preceding form ; a proportion of one to ten would be extreme.
This increase takes place solely in the lymphocytes, all other forms of leu-
cocytes being present in greatly diminished relative proportion. In TJthe-
mann's case ninety-three per cent of all the leucocytes were lymphocytes.
Eosinophiles and nucleated red corpuscles are rare. Myelocytes are not
present. As occasionally combined forms of leukaemia may occur, so un-
doubtedly variations from these two types of blood may be met with, and
in a case of acute leukaemia observed at the Johns Hopkins Hospital, in
which glands, marrow, and spleen were affected, there was present, besides
a large proportion of lymphocytes and myelocytes, a considerable number
of large mononuclear leucocytes. Among other points about leukaemic
blood may be mentioned the feebleness of the amoeboid movement, as noted
by Cafafy, which may be accounted for by the large number of mono-
nuclear elements present, the polynuclear alone possessing this power.
The blood-plates exist in variable numbers ; they may be remarkably
abundant. The fibrin network between the corpuscles is usually thick and
dense. In blood-slides which are kept for a short time, Charcot's octohe-
dral crystals separate, and in the blood of leukaemia the haemoglobin shows
a remarkable tendency to crystallize.
The pulse is usually rapid, soft, compressible, but often full in volume.
There are rarely any cardiac symptoms. The apex beat may be lifted an
interspace by the enlarged spleen. Toward the close, as a consequence of
the feeble circulation, oedema may occur in the feet or there may be gen-
eral anasarca. Haemorrhage is a common symptom and may be either
late or early. Epistaxis is the most frequent form. Haemoptysis and
haematuria are rare. Bleeding from the gums may be present. Haemate-
mesis proved fatal in two of my cases, and in a third a large cerebral
haemorrliage rapidly killed. The leukaemic retinitis is a part of the haem-
orrhagic manifestations.
LEUKEMIA.
701
There are very few pulrnoniiry symptoms. The shortness of breath is
due, as a rule, to the aiia3mia. Toward the end there may be oedema of
1890.
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MEAN NORM.
NUMBER or
WHITE
CORPUSCLES
BLACK, RED CORPUSCLES.
DEO, HAEMOGLOBIN.
('hart XIX. — Leuka'inia.
BLUE, COLORLESS CORPUSCLES.
the lungs or pneumonia may carry off the patient. The gastro-intestinal
symptoms are rarely absent. Nausea and vomiting are early features in
some cases. I)iarrh(p.a may be very troublesome, even fatal. Intestinal
haemorrliage is not common. There may be a dysenteric process in the
colon. Jaundice rarely occurs, though in one case of my series there were
recurrent attacks. Ascites may bo a j)rominent symptom, probably due
702 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
to the presence of the splenic tumor. A leukcGmic peritonitis also may be
present, due to 'new growths in the membranes.
The nervous system is not often involved. Headache, dizziness, and
fainting spells arc due to anaemia. The patients are usually tranquil and
resigned. Sudden coma may follow cerebral haemorrhage.
The special senses are often affected. There is a peculiar retinitis, due
chiefly to the extravasation of blood, but there may be aggregations of
leucocytes, forming small leukaemic growths. Optic neuritis is rare. Deaf-
ness has frequently been observed ; it may appear early and possibly is due
to haemorrhage.
The urine presents no constant changes. The uric acid excreted is
always in excess, and possibly, as Salkowski suggests, stands in direct re-
lation to the splenic tumor.
Priapism is a curious symptom which has been present in a large num-
ber of cases. It may, as in one of Edes' cases, be the first symptom. Peabody
reports a case in which it persisted for six weeks. The cause is not known.
Slight fever is present in a majority of cases. Periods of pyrexia may
alternate with prolonged intervals of freedom. The temperature may
range from 102° to 103°.
The Spleen. — Gradual increase in volume of this organ is the most
prominent symptom in a majority of the cases. Pain and tenderness are
common, though the progressive enlargement may be painless. A creak-
ing fremitus may be felt on palpation. The enlarged organ extends
downward to the right, and may be felt just at the costal edge, or when
large it may extend as far over as the navel. In many cases it occupies
fully one half of the abdomen, reaching to the pubes below and extending
beyond the middle line. As a rule, the edge, in some the notch or notches,
can be felt distinctly. Its size varies greatly from time to time. It may
be perceptibly larger after meals. A ha3morrhage or free diarrhoea may
reduce the size. The pressure of the enlarged organ may cause distress
after eating ; in one case it caused fatal obstruction of the bowels. A
murmur may sometimes be heard over the spleen, and Gerhardt has de-
scribed a pulsation in it.
The Lymph Glands. — Lymphatic leukaemia is rare. As mentioned, in
but 1 of my series of 17 cases were the glands enlarged; indeed, no in-
stance of pure lymphatic leukaemia has come under my observation. The
superficial groups are usually most involved, and even when affected it is
rare to see such large bunches as in Ilodgkin's disease. External lymph
tumors arc rare.
The pure myelogenous cases without associated enhirgement of the
spleen are rare. The most extreme hyperplasia of the bone marrow may
exist without any tenderness. Occasionally the sternum, ribs, and flat
bones show great irregularity and deformity, owing to definite tumor-like
expansions.
Diagnosis. — The recognition of leukaemia can be determined only
LEUKAEMIA. 70
o
by microscopical examination of the blood. The clinical features may bo
identical with those of ordinary splenic anaemia, or with llodgkin's disease
An interesting question arises whether real increase in the leucocytes is
the only criterion of the existence of the disease. Thus, for instance, in
the case whose chart is given, on page 701, the patient came under obser-
vation in September, 1890, with 2,000,000 red blood-corpuscles per cubic
millimetre, thirty per cent of haemoglobin, and 500,000 white blood-cor-
puscles per cubic millimetre — a proportion of one to four. As shown by
the chart, throughout September, October, JSTovember, and December, this
ratio was maintained. Early in January, under treatment with arsenic,
the white corpuscles began to decrease and gradually, as shown in the
chart, the normal ratio was reached. At this time could it be said that
the case was one of leukaemia without increase in the number of leu-
cocytes? The blood examination by Ehrlich's method, as made by
Thayer, showed that the characteristic myelocytes, elements which are not
present in normal blood, were still present in numbers sufficient, at any
rate, to suggest, if the patient had come under observation for the first
time, that leukaemia might occur. By Ehrlich's method of blood exam-
ination a condition of leucocytosis can readily be distinguished from that
of leukaemia, for in all ordinary leucocytoses the increase takes place solely
in the polynuclear neutrophilic leucocytes, forming quite a different pict-
ure from the characteristic conditions described above.
Prognosis, — Recovery occasionally occurs. A great majority of the
cases prove fatal within two or three years. Unfavorable signs are a
tendency to haemorrhage, persistent diarrhoea, early dropsy, and high fever.
Remarkable variations are displayed in the course, and a transient im-
provement may take place for weeks or even months. The pure lym-
phatic form seems to be of particular malignancy, some cases proving
fatal in from six to eight weeks.
Treatment. — Fresh air, good diet, and abstention from mental worry
and care, are the important general indications. The indicatio morbi can-
not be met. There are certain remedies wliicli have an influence upon
the disease. Of these, arsenic, given in large doses, is the best. I have
repeatedly seen improvement under its use. On the other hand, there are
curious 1 emissions in the disease which render tlicrapeutical deductions
very fallacious. I have seen such marked improvement without special
treatment that the patient, from a bed-ridden, wretched condition, recov-
ered strength enough to enable him to attend to light duties.
Quinine may be given in cases with a malarial history. Iron may be
of value in some cases, as may also inhalations of oxygen.
Excision of the leukaemic spleen has been performed twenty-four times,
with one recovery — the case of Franzolini. Fusscll gives the statistics
of 105 cases of splenectomy with 48 deaths. Of the cases of simple
hypertrophy, 28 m number, 9 recovered. Of 10 cases of floating spleen,
15 recovered.
704: DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
III. HODGKIN'S DISEASE.
Definition. — An affection characterized by progressive hyperplasia
of tlie lymph glands, with anaemia, and occasionally the development of
secondary lymphoid growths in liver, spleen, and other organs. The dis-
ease has also the names pseudo-leukcemia^ general lymphadenoma, and
adenie.
Hodgkin, the well-known morbid anatomist of Guy's Hospital, first
described cases in detail, and by the labors of Wilks, Virchow, Billroth,
and Cohnheim the disease attained definite recognition.
Etiology. — A majority of the cases are in young persons. In Gowers'
table of 100 cases, 30 were under twenty years, 34 between twenty and
forty, and 36 above forty. Three fourths of the cases are in males. In a
few instances heredity has been adduced as a possible cause, and antece-
dent disease, such as syphilis, but this is doubtful. More important is local
irritation, upon which Trousseau lays special stress, and gives instances in
which chronic irritation of the skin, chronic nasal catarrh, or the irrita-
tion of a decayed tooth gave rise to local gland swellings, which preceded
a general development of the disease. In a large majority of the cases the
disease comes on insidiously, without any recognizable cause.
Morbid Anatomy. — The Lijmpli Glands. — In a few cases the en-
larged glands are hard and firm, but in a majority the growth is soft and
elastic. In the early stage the individual glands are isolated, not larger
than almonds or walnuts, and readily separated and movable. AVhen ad-
vanced the glands fuse together, and a group, as in the neck, may form a
large tumor, the size of an orange or even of a cocoa-nut. About such
masses the capsular tissues are hard and dense, forming a firm investment.
A growth may perforate the capsule and invade contiguous parts, such as
the muscles, skin, or the solid organs. On section, the tumor has a gray-
ish-white appearance ; it is smooth, and of variable consistence, either firm
and dry or soft and juicy. Suppuration is most frequently seen when the
growth reaches the skin. In the deep glands the formation of pus is rare.
Caseation is not common ; occasionally there are areas of necrosis very
like it. The superficial glands are most often attacked, particularly the
cervical groups, and the glands may be traced as continuous chains along
the trachea and the carotids, uniting the axillary and mediastinal glands.
The axillary group is involved next in order of frequency, and the
masses may pass beneath the pectorals and beneath the scapulae. The
inguinal glands occasionally form very large masses. Of the internal
groups, those of the thorax are most often affected, either the chain in tlie
posterior mediastinum or the bronchial group, or those of the anterior
mediastinum. The trachea and the aorta with its branches may be com-
pletely surrounded by the growths, and be but little compressed. From
the anterior mediastinum the masses may perforate the sternum and ap-
pear as an external tumor.
HODGKIN'S DISEASE. Y05
Of the abdominal groups, the retroperitoneal is most frequently in-
volved and may form a continuous chain from the diaphragm to the
inguinal canals, and extend into the pelvis. The glands may compress the
ureters, involve the sacral or lumbar nerves, or compress the iliac veins.
Occasionally they adhere to the uterus and broad ligament so as to simu-
late fibroids. I saw, some years ago, one of the most distinguished gynae-
cologists of Germany perform laparotomy in a case of this kind, in which
the diagnosis of myomatous tumors of the uterus had been made. Occa-
sionally the mesenteric or hepatic lymph glands may form large abdominal
tumors.
Histologically the chief change is an increase in the cells, with or
without thickening of the reticulum. In the early stage there is simple
hyperplasia and the relations of the lymph paths are maintained, but when
the glands are greatly enlarged the normal arrangement is disturbed. The
reticulum varies extremely ; in the softer growths it is expanded and can
scarcely be found ; in the harder structures the network of fibres is very
distinct, and there is probably an increased development of the adenoid
tissue.
Spleen. — In seventy-five per cent of the cases collected by Gowers this
organ was hypertrophied, and in fifty-six of these cases it presented lym-
phoid growths. The enlargement is rarely great, and does not approximate
to the large leukaemic spleen. The lymphoid tumors form grayish-white
bodies ranging in size from a pea to a walnut, and may resemble lymph
glands in appearance and consistence. Histologically, they consist of
lymph corpuscles in a fibrous reticulum.
The marrow of the long bones may be converted into a rich lymphoid
tissue ; in a few instances the pyoid form, such as is more common in leu-
kaemia, has been found. The tonsils may be involved and the follicles at
the root of the tongue. Occasionally secondary growths are seen in the
intestines.
The liver is often enlarged and may present scattered lymphoid tumors.
The kidneys are occasionally involved and are the seat of growths similar
to those of the spleen and liver. The lungs are occasionally directly at-
tacked from the bronchial glands at the root, and secondary nodules may be
found throughout their substance. Pleural effusions are not uncommon.
Involvement of the nervous system is rare, but paraplegia may be induced
by invasion of the spinal canal. The skin may be the seat of adenoid
growths, as in a case reported by Greenfield.
Symptoms. — Enlargement of the glands of the neck, axilla, or
groins is usually the first symptom noticed. In a few cases the anaemia
and constitutional symptoms attract attention before the glandular in-
volvement is evident. When the trouble begins in the deeper groups,
pressure effects may be first noticed ; thus, paroxysmal dyspnoea with pain
in the chest may result from enlargement of the bronchial glands before
any physical signs can be detected. Gi^dema of the feet and shooting
706 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
pains in the nerves were the first symptoms in one case which I dis-
sected for Ross, and in another case at the Montreal General Hospital
there was paraplegia from pressure on the cord. Such instances, however,
are exceptional, and in the majority of cases the swelling of the superficial
glands is the earliest symptom. Epistaxis has occasionally been noted, but
not so frequently as in leukasmia. AVith progressive enlargement of the
glands the patient becomes anaemic.
Usually, the cervical group is first affected, and it may be impossible
to decide whether the enlargement is syphilitic, tuberculous, or lymphad-
enomatous. One side is first affected as a rule, and it may be months, or
even, as in one of my cases, three years before the affection extends to
other groups. Ultimately huge tumors may develop, which obliterate the
neck and extend upon the shoulders and over the clavicles and sternum.
The trachea is surrounded, great dyspnoea is produced, and not infre-
quently tracheotomy is necessary. In the later stages, the skin becomes
involved and ulcerates. The axillary group may form large tumors, which
compress the brachial or axillary veins and cause swelling of the arms.
The inguinal glands are not so often involved, but may form large or
even pendulous tumors.
In the thoracic glands, as mentioned, the various groups may be in-
volved and produce pressure upon the veins or upon the trachea. In a
case at present under observation the superior cava is completely obliter-
ated and a very extensive collateral circulation has been established by
means of the mammary and epigastric veins. The skin over the sternum
is a mass of fluctuating veins, some of which contain phleboliths. In the
abdomen the mesenteric glands may be enlarged, or more commonly the
retroperitoneal group. When the patient is thin there may be no diffi-
culty in detecting these, but in stout persons the diagnosis may be impos-
sible. In connection with the affections of the abdominal glands there
may be bronzing of the skin, which was well marked in Case IV of my
series. A remarkable feature is the variations in the rate of growth and
in the size of the glands. They may reduce rapidly and almost disappear
from a region, and before death the tumors may diminish very much.
The spleen may be enlarged and readily palpable. The thyroid also may
be involved, and in a few instances the thymus has been affected. Though
present in a majority of the cases, there may be enormous enlargement of
the lymph glands without marked anaemia. In one of my cases the blood-
corpuscles did not sink below 4,000,000 per cubic millimetre, and in only
one instance have I counted the blood below 2,000,000. The red blood-
corpuscles rarely show extreme poikilocytosis. The white corpuscles may
be moderately increased and the lympliocytes most abundant. Occasion-
ally the leucocytes are greatly increased and the characters of the blood
become those of a lymphatic leukaemia. Nucleated red blood-corpuscles
may be present, but not in such numbers as in leukaemia.
Of cardiac symptoms, palpitation is common, lla^mic murmurs are
HODGKIN'S DISEASE. Y07
often heard over the heart. Shortness of breatli may be due to the anaemia,
to pressure upon the trachea, or, in some instances, to pleuritic effusion
associated with mediastinal growths. Fever is observed in nearly all cases ;
even in the early stages there is slight elevation. It may be of an irregu-
lar hectic type, or continuous, with evening exacerbation. Very remarka-
ble are the cases with ague-like paroxysms, which may persist for weeks
or months. They were present in Case I of my series. Pel, of Amster-
dam, has given a thorough description of these attacks, and Ebstein has
described a case under the remarkable title of " Chronic Recurrent Fever, a
New Infectious Disease." In his case during nine months the attacks were
present for periods of from twelve to fourteen days and alternated with
apyrexia for ten or eleven days.
The digestive symptoms are usually not marked. It is not uncommon
to find albumen in the urine. Headache, giddiness, and noises in the ear
may be associated with the anaemia. Delirium and coma may be present.
Deafness may be produced by grow^th of the adenoid tissue in the phar-
ynx close to the Eustachian tubes. Inequalit}^ of the pupils may be pres-
ent, owing to pressure of the glands on the cervical sympathetic. The skin
may show definite secondary lymphatic tumors, bronzing may occur, and
occasionally a most intense and troublesome prurigo.
Diagnosis. — A tuberculous adenitis may at first be very difficult
to differentiate. The chief points of distinction are as follows : Tuber-
culous adenitis is more common in the young and involves the submaxil-
lary group of glands more frequently than those of the anterior and pos-
terior cervical triangles, which are usually affected first in Hodgkin's
disease. The enlargement may last for years in a group without extend-
ing. The bunches are often, when small, welded together and, most im-
portant of all, tend to suppurate — a feature rarely seen in true lymphade-
noma, except when it has attained very large size. Strict limitation to
one side of the neck or to the axilla is suggestive of tuberculous disease
rather than lymphadenoma.
There is an acute tuberculous adenitis, which may involve the lymph
glands of the neck, producing enormous enlargement. A man, aged twenty-
four, was admitted to the General Hospital, Montreal, with great swelling of
the cervical glands on both sides, tonsillitis, and sloughing pharyngitis,
with irregular fever and diarrhoea. The case was at first regarded as one
of Hodgkin's disease. The occurrence of rigors and intermittent pyrexia
is in favor of lymphadenoma. There are cases in which it may for a
time be impossible to make a diagnosis. When the glands are only mod-
erately enlarged on one side of the neck or axilla, they should be removed,
and the diagnosis can then be thoroughly established.
Prognosis. — Recovery is very rare. The course of the disease is ex-
tremely variable. Early and rapid growth in the mediastinal groups may
produce pressure effects and cause death before the development is ex-
treme. In some cases the enlargements spread rapidly and group after
45
708 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
group becomes involved in a few months. These acute cases may run a
course in three or four months. Chronic cases may last for three or four
years. Periods of quiescence are not uncommon. The tumors may not
only cease to grow, but gradually diminish and even disappear, without
special treatment. Usually a cachexia develops, the anaemia progresses,
and there are dropsical symptoms. The mode of death is usually by
asthenia ; less commonly by pressure from a tumor ; and occasionally by
coma.
Treatment. — When small and localized the glands should be removed.
Local applications are of doubtful benefit. I have never seen special im-
provement follow the persistent use of iodine or the various ointments.
Arsenic has a positive value in the disease. It should be given in in-
creasing doses, and stopped when unpleasant effects are manifested. The
results have in many instances been striking. Due allowance must be
made for the fluctuations in the size of the growths which occur sponta-
neously. I have seen no ill effects from the administration of Fowler's
solution for months at a time, and many patients have taken from fifteen
to twenty minims three times a day for weeks, and in some instances for
months. Recoveries have been reported under this treatment. Person-
ally, no instance of recovery has come under my notice in the cases of
which I have notes. Phosphorus is recommended by Gowers and Broad-
bent, and should be used if the arsenic is not well borne. Quinine, iron,
and cod-liver oil are useful as tonics. Every possible means must be
taken to support the patient's strength.
IV. ADDISON'S DISEASE.
Deflnition. — A constitutional affection characterized by asthenia,
depressed circulation, irritability of the stomach, and pigmentation of the
skin. In a majority of the cases it is associated with tuberculous disease
of the adrenals, in other instances with wasting of these organs or with
changes in the abdominal sympathetic system.
The recognition of the disease is due to Addison, of Guy's Hospital,
whose monograph on The Constitutional and Local Effects of Disease of
the Suprarenal Capsules was published in 1855.
Etiology. — Males are more frequently attacked than females. In
Greenhow's analysis of 183 cases 119 were males and 64 females. A ma-
jority of the cases occur between the twentieth and the fortieth year. A
congenital case has been described in which the skin had a yellow-gray
tint. The child lived for eight weeks, and post mortem the adrenals were
found to be large and cystic. Injury, such as a blow upon the abdomen
or back, and caries of the spine have in many cases preceded the attack.
The disease is rare in America. Eight cases have come under my per-
sonal observation, either clinically or anatomically.
ADDISON'S DISEASE. 7()9
Morbid Anatomy and Pathology. — There is rarely emaciation
or anaemia. In a great majority of the cases the adrenals are affected.
There may be (a) atrophy of one or both glands, due to an interstitial
cirrhosis, of which cases have been described by lladden and Goodhart.
(b) Tuberculosis, which is the common condition. The capsules are thick-
ened and present firm caseous masses, surrounded by connective tissue.
There is usually much fibrous thickening and matting of the adjacent
structures, and the affection has definitely been shown to be tuberculous.
Tuberculous lesions are common in other parts, particularly in the lungs,
though in a number of the cases tuberculosis has been limited to the
adrenals, (c) There may be malignant disease of the adrenals, which has
been present in a few instances of genuine Addison's disease. Among
other anatomical features the condition of the abdominal sympathetic has
been specially studied. The nerve-cells of the semilunar ganglia have
been described as degenerated and deeply pigmented, and the nerves scle-
rotic. The ganglia are not uncommonly entangled in the cicatricial tissue
about the adrenals. The spleen has occasionally been found enlarged ; the
thymus may persist and be larger than normal.
It is difficult to explain satisfactorily all the symptoms of this remark-
able disease. The theories which have been advanced are briefly as follows :
(a) That the disease depended upon the loss of function of the adrenals.
This was the view of Addison. It is held that the blood is gradually
poisoned by the retention of some material, the destruction or alteration
of which is a function of the suprarenals ; (b) that it is an affection of
the abdominal sympathetic system, induced most commonly by disease of
the adrenals, but also by other chronic affections which involve the solar
plexus and its ganglia. According to this view, it is an affection of the
nervous system, and the pigmentation has its origin in changes induced
through the trophic nerves. The pronounced debility is the outcome of
disturbed tissue metabolism, and the circulatory, respiratory, and digestive
symptoms are due to implication of the pneumogastric. The changes
found in the abdominal sympathetic are held to support this view, and its
advocates urge the occurrence of pigmentation of the skin in tuberculosis
of the peritonaeum, cancer of the pancreas, or aneurism of the abdominal
aorta. Opposed to it are the facts that the lesions described in the sym-
pathetic system are indefinite, and identical changes occur without the
symptoms of Addison's disease.
Symptoms. — In the words of Addison the characteristic symptoms
are " anaemia, general languor or debility, remarkable feebleness of the
heart's action, irritability of the stomach, and a peculiar change of color
in the skin."
The pigmentation is the symptom which, a§ a rule, first attracts at-
tention. The grades of coloration range from a light yellow to a deep
brown, or even black. In typical cases it is diffuse, but always deeper on
the exposed parts and in the regions where the normal pigmentation is
7L0 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
most intense. At first it may be confined to the face and hands. Occa-
sionally it is absent. Patches of atrophy of pigment, leucoderma, may oc-
cur. The pigmentation is found on the mucous membranes of the mouth,
conjunctivae, and vagina. A patchy pigmentation of the serous mem-
branes has often been found. The anaemia, upon which Addison laid
stress, is of a moderate grade. It was not present in a marked degree in
any of my cases.
Gastric disturbances are common ; nausea and vomiting may be early
and prominent symptoms ; diarrhoea, too, is frequent, and may come on
without cause. The pulse is small and rapid, and the heart's action
feeble. Sometimes there is a special liability to syncope. One of the
most pronounced features of the disease is the profound asthenia, which
is out of all proportion to the general condition. The patient complains
of a lack of energy, both mental and bodily; the least exertion is an
effort, and may be folloAved by giddiness or noises in the ears. Headache
is a frequent symptom. With the advancement of the disease the prostra-
tion becomes more marked, the patient remains in bed, the voice gets
weak, the intelligence dulled, and death occurs either by syncope or
gradual asthenia. Occasionally there are convulsions. The urine is
usually normal. Polyuria has been described. The urinary pigm.ents
have been found increased.
Diagnosis. — Pigmentation of the skin is not confined to Addison's
disease. The following are the conditions which may give rise to an in-
crease in the pigment :
(1) Abdominal growths — tubercle, cancer, or lymphoma. In tuber-
culosis of the peritonaeum pigmentation is not uncommon.
(2) Pregnancy, in which the discoloration is usually limited to the
face, the so-called masque des femmes enceinte. Uterine disease is a
common cause of a patchy melasma.
(3) Hepatic disease, which may induce definite pigmentation, as in
the diabetic cirrhosis. More commonly in overworked persons of con-
stipated habit and with sluggish livers there is a patchy staining about
the face and forehead.
(4) The vagabond's discoloration, caused by the irritation of lice and
dirt, which may reach a very high grade, and has sometimes been mis-
taken for Addison's disease.
(5) In rare instances there is deep discoloration of the skin in mela-
notic cancer, so deep and general that it has been confounded with melasma
suprarenale.
(G) In certain cases of exophthalmic goitre abnormal pigmentation
occurs, as noted by Drummond and others.
In any case of unusual pigmentation tliese various conditions must
be sought for, and the diagnosis of Addison's disease is scarcely jus-
tifiable without the asthenia. In many instances it is difficult early
in the disease to arrive at a definite conclusion. The occurrence of
DISEASES OP THE THYROID GLAND. 711
fainting fits, of nausea, and gastric irritability is an important indica-
tion.
Prognosis. — The disease is usually fatal. The cases in which the
bronzing is slight or does not occur run a more rapid course. There are
occasionally acute cases which, with great weakness, vomiting, and diar-
rhoea, prove fatal in a few weeks. In a few cases the disease is much
prolonged, even to six or ten years. In rare instances recovery has taken
place, and periods of improvement, lasting many months, may occur.
Treatment. — The causal indications cannot be met. When there
is profound asthenia the patient should be confined to bed, as fatal
syncope may at any time occur. In three of my cases death was sudden.
When anaemia is present iron may be given in full doses. Arsenic and
strychnia are useful tonics. For the diarrhoea large doses of bismuth
shoidd be given ; for the irritability of the stomach, creosote, hydrocyanic
acid, ice, and champagne. The diet should be light and nutritious.
Many patients thrive best on a strictly milk diet.
V. DISEASES OF THE THYROID GLAND.
Goitre.
Definition. — Hypertrophy of the thyroid gland, occurring sporadi-
cally or endemically.
In this country sporadic cases are common. Endemically it is found
particularly in the mountainous regions of Switzerland and in parts of
Italy. No satisfactory explanation has been given of the existence of the
disease in this form.
Anatomically the following varieties may be distinguished : (a) Paren-
chymatous, in which the enlargement is general and the follicles, usually
newly formed, contain a gelatinous colloid material, (b) Vascular, in
which the enlargement is chiefly due to dilatation of the blood-vessels
without the new formation of glandular tissue, (c) Cystic goitre, in which
the enlarged gland is occupied by large cysts, the walls of which often
undergo calcification.
Symptoms. — The enlargement may be uniform throughout the
entire gland, or affect only one lobe, or the isthmus alone. When small,
a goitre causes no inconvenience. In its growth it may compress the
trachea, causing dyspnoea, or may pass beneath the sternum and compress
the veins. 1'hese, however, are exceptional circumstances, and in a large
proportion of all cases no serious symptoms are noted. The affection
usually comes under the care of the surgeon. Sudden death occasionally
occurs in large bronchoceles. In some instances it may be difficult to de-
termine the cause and it has been thought to be associated with pressure
on the vagi. I have reported an instance in which it resulted from haemor-
712 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
rliage into the gland and into the adjacent tissues. The blood passed into
the cellular tissues of the neck and into the sternum, covering the aorta
and pericardium.
Tumors of the Thyroid.
These are very varied, (a) Adenomata, either simple or malignant.
The latter may form extensive metastases. A case is reported by Hay-
ward in which growths resembling thyroid tissue occurred in the lungs and
various bones of the body, (b) Cancer, of which several forms have been
described, (c) Sarcoma. All of these have a surgical rather than a
medical interest.
It may be mentioned that the aberrant or accessory thyroid gland may
form large tumors in the mediastinum or in the pleura. I have reported
two cases of this kind,* and an instance is on record in which an enor-
mous cystic accessory thyroid occupied the entire right pleura.
Exophthalmic Goitre {Graves'^s Disease; Basedow^ s Disease).
Definition. — A disease of unknown origin, characterized by exoph-
thalmos, enlargement of the thyroid, and functional disturbance of the
vascular system.
Etiology. — The disease is rare in men. The age of onset is usually
from the twentieth to the thirtieth year. It is sometimes seen in several
members of the same family. Worry, fright, and depressing emotions
precede the development of the disease in a number of cases.
Morbid Anatomy and Pathology. — No constant changes have
been found in exophthalmic goitre. Special attention has been paid to
the condition of the sympathetic system, as the rapid action of the heart
and dilatation of the vessels has been attributed to paralysis of the sympa-
thetic fibres, particularly the vaso-dilators. This view has found many
supporters, but neither in the ganglia nor in the nerves are there any
changes which can be regarded as constant and peculiar (Hale White).
On the other hand, many features of the disease are explicable on the
view that it is an affection of the medulla oblongata, and Hale White
has reported a case dying of an acute intercurrent disease in which there
were haemorrhages in the floor of the fourth ventricle. The vascular and
nervous features might be due to a lesion of this part ; but it is difficult
on any tlieory to explain all the symptoms of the disease and to bring
into line the mental and vascular phenomena, the exophthalmos and the
goitre.
Symptoms. — Acute and chronic forms may be recognized. In the
acute form the disease may develop with great rapidity. In a patient of
J. H. Lloyd's, of Pliiladelphia, a woman, aged thirty-nine, who had been
considered perfectly healthy, but whose friends had noticed that for
* Medical News, 1890.
DISEASES OF THE THYROID GLAND. 713
some time her eyes looked rather prominent, was suddenly seized with
intense vomiting and diarrhoea, rapid action of the heart, and great throb-
bing of the arteries. The eyes were prominent and staring and the
thyroid gland was found much enlarged and soft. The gastro-intestinal
symptoms continued, the pulse became more rapid, the vomiting was in-
cessant, and the patient died on the third day of the illness ; only the
abdominal and thoracic organs could be examined and no changes were
found. Two rapidly fatal cases occurred at the Philadelphia Hospital,
one of which, under F. P. Henry's care, had marked cerebral symptoms.
More frequently the onset is gradual and the disease is chronic. The
three characteristic symptoms vary a good deal in their onset. Cardiac
and vascular symptoms are usually first to develop and the patient com-
plains of palpitation with breathlessness, and on examination the im-
pulse is found to be increased in force, the apex beat is in normal posi-
tion, the carotids throb, and the abdominal aorta pulsates visibly. This
is one of the conditions in which the capillary pulse and the pulsation in
the veins of the hands are occasionally seen. The pulse-rate at first may
not be more than 95 or 100, but when the disease is established may reach
140 or 160. Any emotional excitement sets the heart beating with great
intensity, and on exposure of the skin of the upper part of the chest a
transient hyperasmia is seen. Soft murmurs are not uncommon at the
base of the heart. In the long-standing cases the heart may be hypertro-
phied and the sounds very intense. In rare instances they may be heard
some distance from the patient ; according to Graves, as far as four feet.
Exophthalmos usually follows the vascular disturbance. It is readily
recognized by the protrusion of the balls, and partly by the fact that the
lids do not completely cover the sclerotics, so that a rim of white is seen
above and below the cornea. The protrusion may become very great and
the eye may even be dislocated from the socket. The vision is normal.
Graefe noted that when the eyeball is moved downward the upper lid does
not follow it as in health. This is known as Graefe's sign. The palpe-
bral aperture is wider than in health, owing to spasm or retraction of the
upper lid (Stell wag's sign). Changes in the pu2:>ils and in the optic nerves
are rare. Pulsation of the retinal arteries is common.
The enlargement of the thyroid commonly develops with the exoph-
thalmos. It may be general or in only one lobe, and is rarely as large as
in ordinary goitre. The vessels are usually much dilated, and the whole
gland may be seen to pulsate. A thrill may be felt on palpation and on
auscultation a loud systolic murmur, or more commonly a br^uit de diahle.
Among other symptoms which may develop are anaemia, emaciation, and
slight fever. Attacks of vomiting and diarrhoea may occur. Tremor is
present in many cases, involving the hands, and is usually very fine. The
greatest complaint is of the unpleasant throbbing in the arteries, often
accompanied with unpleasant flushes of heat and profuse perspirations.
Skin symptoms are not infrequent — pigmentation, patches of leucoderma,
7U DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
or atrophy of pigment, and urticaria. In the very acnte case above re-
ferred to, urticaria was a prominent symptom. Irritability of temper,
change in disposition, and great mental depresssion have been described.
An important complication is acute mania, in which the patient may die
in a few days. Symptoms of general paresis have been noted in a few
cases. A feature of interest noted by Charcot is the great diminution in
the electrical resistance, which may be due to the saturation of the
skin with moisture owing to the vaso-motor dilatation (Hirt). Bry-
son has noted the fact that the chest expansion may be greatly dimin-
ished.
The course of the disease is usually chronic, lasting several years.
After persisting for six months or a year the symptoms may disappear.
There are remarkable instances in which the symptoms have come on with
great intensity, following fright, and have disappeared again in a few days.
A certain proportion of the cases recover, but when the disease is well de-
veloped recovery is rare.
Treatment. — Medicinal measures are notoriously uncertain. The
combination of digitalis and iron may be tried, and, when there is anaemia,
often does good. I have never seen any advantage from the use of aco-
nite or veratrum viride. The tincture of strophanthus will sometimes
reduce the rapidity of the heart's action. Ergot is warmly recommended
by some writers. Belladona gives relief occasionally, and should be ad-
ministered until the dryness of the throat is obtained. No measures are
so successful as rest in bed with an ice-bag or Leiter's tube applied oc-
casionally over the heart, or, what is sometimes more agreeable, over the
lower part of the neck and manubrium sterni. I have known the pulse
to be reduced in this way from 140 to 90. Electricity has been much
lauded and instances of cure have been reported. In many cases tem-
porary improvement certainly follows the use of the galvanic current, the
cathode being placed at the back of the neck and the anode along the
course of the sympathetic or over the heart. Treatment of the thyroid
gland itself is rarely successful, and the operative measures have not been
very satisfactory. Ligation of the arteries of the thyroid has been tried.
Myxcedema.
Definition. — A constitutional affection, characterized clinically by a
myxoedematous condition of the subcutaneous tissues and mental failure,
and anatomically by atrophy of the thyroid gland. The disease was de-
scribed by Sir William Gull as a cretinoid change, and by Ord as a special
disease, to which ho gave the above name.
Clinical Forms. — Three groups of cases may be recognized: (a)
Congenital form ^ or sporadic cretinism. In these cases there is congenital
absence of the thyroid, and the child is a dwarf, having a thick neck, short
arms and legs, and prominent abdomen. The face is large, the lips are
DISEASES OF THE THYROID GLAND. 715
thick, the tongue is liirgo and usually protrudes. The mental condition
is that of imbecility or idiocy.
(b) Myxwdema Pro2)er. — In this, women are very much more frequently
affected than men — in a ratio of one to six. The disease may affect several
members of a family, and it may be transmitted through the mother. In
some instances there has been first the appearance of exophthalmic goitre.
Though occurring most commonly in women, it seems to have no special
relation to the catamenia or to pregnancy, though in one instance the
symptoms of myxoedema disappeared during pregnancy. It is not so com-
mon in this country as in England. The symptoms of this form, as given
by Ord,* are marked increase in the general bulk of the body, a firm, in-
elastic swelling of the skin, which does not pit on pressure, dryness and
roughness, which tend, with the swelling, to obliterate in the face the lines
of expression, imperfect nutrition of the hair, local tumefaction of the skin
and subcutaneous tissues, particularly in the supraclavicular region. The
physiognomy is altered in a remarkable way, the features are coarse and
broad, the lips thick, the nostrils broad and thick, and the mouth is en-
larged. Over the cheeks, sometimes the nose, there is a reddish patch.
There is a striking slowness of thought and of movement. The memory
becomes defective, the patients become irritable and suspicious, and there
may be headache. In some instances there are delusions and hallucina-
tions, leading to a final condition of dementia. The gait is heavy and
slow. The temperature may be below normal. The functions of the
heart, lungs, and abdominal organs are normal. Haemorrhage sometimes
occurs. Albuminuria is sometimes present, more rarely glycosuria. Death
is usually due to some intercurrent disease. The thyroid gland is dimin-
ished in size and may become completely atrophied and converted into a
fibrous mass. The subcutaneous fat is abundant and in one or two in-
stances a great increase in the mucin has been found.
The course of the disease is slow but progressive, and extends over ten
or fifteen years. I have recently had under observation a case to which
the term acute myxoedema might be applied. A young man, aged twenty,
presented a gradual enlargement of the face, particularly of the lips and
cheeks and nose, without actual oedema. The backs of the hands were
also swollen, but did not pit. The condition came on with enlargement
of the thyroid, and, after persisting for between three and four months,
is now gradually subsiding.
(c) Operative Myxedema ; Cachexia Strumipriva. — Ilorsley, in a series
of interesting experiments, showed that complete removal of the thyroid
in monkeys was followed by the production of a condition similar to that of
myxdidema and often associated with spasms or tetanoid contractures, and
followed by apathy and coma. AV'hen the monkeys were kept warm myx-
csdema was averted, and, instead of an acute myxoedema, the animals devel-
* Report on Myxoedema, Clinical Society's Transactions, 1888.
71G DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
oped a condition which closely resembled cretinism. An identical condi-
tion may follow extirpation of the thyroid in man. Kocher, of Bern,
found tliat after complete extirpation a cachectic condition followed in
many cases, the symptoms of which are practically identical with those of
myxoedema. Tlie disease follows only a certain number of total and a
much smaller proportion of partial removals of the thyroid gland. Of
408 cases, in 69 the operative myxoedema developed. It has been thought
that if a small fragment of the thyroid remains, or if there are accessory
glands, which in animals are very common, these symptoms do not de-
velop. It is possible that in men, in the cases of complete removal, the
accessory fragments subserve the function of the gland. Operative myxoe-
dema is very rare in this country ; the only case of which I know is a
patient of McGraw's, of Detroit.
It is evident that the thyroid gland supplies some essential secretion
of first importance to normal metabolism. What this is or how it acts
is at present beyond our knowledge.
The diagnosis of the disease is easy. Bright's disease is the only con-
dition for which it could be readily mistaken, but the absence of pitting,
the curious condition of the face, and the absence of albumen in the urine
are features which would readily distinguish it.
Unfortunately, no satisfactory treatment is known. The patients suf-
fer in cold and improve greatly in warm weather. They should, there-
fore, be kept at an even temperature, and should, if possible, move to a
warm climate during the winter months.
SECTION VII.
DISEASES OF THE KIDNEYS.
I. ANOMALIES IN FORM AND POSITION.
Anomalies in Form. — These rarely come within the scope of the phy-
sician. Atrophy or congenital absence of one kidney is associated with
great enlargement of the other organ. Fused kidneys may have a horse-
shoe shape, or both organs may form a large mass, which is often dis-
placed, being either in an iliac fossa or in the middle line of the abdomen,
or even in the pelvis. Under these circumstances it may be mistaken for
a new growth. In Polk's case the organ was removed under the belief
that it was a floating kidney.* The patient lived eleven days, had com-
plete anuria, and it was found post mortem that a single unsymmetrical
kidney, as this form is called, had been removed.
Movable Kidn^ey
{Floating Kidney ; Palpable Kidney ; Ren mohilis ; Nephroptosis).
The kidney is held in position by its fatty capsule, by the peritonaeum
which passes in front of it, and by the blood-vessels. The lower edge
of the left kidney is nearly two inches from the iliac crest, a little below
the level of the second lumbar spine ; that of the right is usually from one
half to three quarters of an inch lower. Normally the kidney is firmly
fixed, but under certain circumstances one or another organ, more rarely
both, becomes movable. In rare cases the kidney is surrounded, to a
greater or less extent, by the peritonaeum, and is anchored at the hilus
by a mesonephron. Some would limit the term floating kidney to this
condition.
Movable kidney is almost always acquired. It is most common in
women. Of the 667 cases collected in the literature by Kuttner, 584
were in women and only 83 in men. It is more common on the right
than on the loft side. Of 727 cases analyzed by this author, it occurred
on the right in 553 cases, on the left in 81, and on both sides in 93. The
* New York Medical Journal, 1883.
718 DISEASES OF THE KIDNEYS.
greater frequency of the condition in women may be attributed to com-
pression of the lower thoracic zone by tight lacing, and, more important
still, to the relaxation of the abdominal walls which follows repeated
pregnancies. This does not account for all the cases, as movable kidney
is by no means uncommon in nulliparae. Drummond believes that in a
majority of the cases there is a congenitally relaxed condition of the peri-
toneal attachments. Wasting of the fat about the kidney may be a cause in
some instances. Trauma and the lifting of heavy weights are occasionally
factors in its production. The kidney is sometimes dragged down by
tumors. The greater frequency on the right side is probably associated
witli the position of the kidney just beneath the liver, and the depression
to which the organ is subjected with each descent of the diaphragm in
inspiration.
And, lastly, movable kidney is met with in many cases which present
that combination of neurasthenia with gastro-intestinal disturbance which
has been described by Glenard * as enteroptosis.
To determine the presence of a movable kidney the patient should be
placed in the dorsal position, with the head moderately low and the ab-
dominal walls relaxed. The left hand is placed in the lumbar region
behind the eleventh and twelfth ribs ; the right hand in the hypochon-
driac region, in the nipple line, just under the edge of the liver. Bimanual
palpation may detect the presence of a firm, rounded body just below the
edge of the ribs. If nothing can be felt the patient should be asked to
draw a deep breath, when, if the organ is palpable, it is touched by the
fingers of the right hand. Various grades of mobility may be recognized.
It may be possible barely to feel the lower edge on deep palpation — palpa-
Ue kidney — or the organ may be so far displaced that on drawing the
deepest breath the fingers of the right hand may be in a thin person
slipped above the upper end of the organ, which can be readily held
down, but cannot be pushed below the level of the navel — movable kidney.
In a third group of cases the organ is freely movable, and may even be
felt just above Poupart's ligament, or may be in the middle line of the
abdomen, or can even be pushed over beyond this point. To this the
idYm. floating kidney is appropriate, whether the organ has a mesonephron
or not.
And, lastly, a dislocated kidney may become fixed in an abnormal
position. This is extremely rare, and in a very large number of cases I
have found only one instance of the kind. A woman, aged twenty-nine,
with four children, had nervous symptoms with abdominal pain, and had
been mucli worried by the discovery of a tumor, just to the riglit of the
middle line, close to the navel. It was not movable, but the distinctly
reniform shape and tlie depression at the left margin indicated that it
was doubtless a dislocated kidney which had become fixed.
* Revue de Medccine, 1887 ; Pourcelot, Paris Thesis, 1889.
ANOMALIES IN FORM AND POSITION. 719
The movable kidney is not painful on pressure, except when it is
grasped very firmly, when there is a dull pain, or sometimes a sickening
sensation. Examination of the patient from behind may show a distinct
flattening in the lumbar region on the side in which the kidney is mobile.
Symptoms. — In a large majority of cases the condition gives no
trouble, and it is well, if detected accidentally, not to let the patient know
of its presence. In other instances there is pain in the lumbar region or
a sense of dragging and discomfort, or there may be intercostal neuralgia.
In a large group the symptoms are those of neurasthenia with dyspeptic
disturbance. In women the hysterical symptoms may be marked, and in
men various grades of hypochondriasis. The gastric disturbance is usu-
ally a form of nervous dyspepsia. Dilatation of the stomach has been ob-
served, owing, as suggested by Bartels, to pressure of the dislocated kidney
upon the duodenum. This view has been supported by Oser, Landau, and
Ewald. On the other hand, Litten holds that the dilatation of the stom-
ach is the cause of the mobility of the kidney, and he found in 40 cases
of depression and dilatation of the stomach 22 instances of dislocation of
the kidney on the right side. My own experience coincides with that of
Drummond, who has very exceptionally found the two conditions to co-
exist. While not denying the possibility of causal relationship between
the two, it seems probable, considering the frequency of floating kidney,
that the complication is only a coincidence. The association, however,
with a depressed stomach is certainly not uncommon in women. Consti-
pation is not infrequent. Some writers have described pressure upon the
gall-ducts, with jaundice, but it is not very likely to occur.
Under the name enteroptosis^ Glenard has described a special symp-
tom group characterized by nervous dyspepsia, prolapse of the abdominal
organs, particularly the transverse colon, with looseness of the mesenteric
and peritoneal attachments, so that there is a falling down of the viscera
(splanchnoptosis). Dilatation of the stomach and mobility of the kidney
are very commonly associated with this state. Glenard held that he could
feel the prolapsed transverse colon as a narrow band, but Ewald states
correctly that this is the pancreas, which in many of these cases can be
distinctly palpated. According to Glenard, the kink in the colon causes
the constipation, while the depression of the stomach and intestines leads
to vascular disturbance and impairment of the motor and secretory
functions.
In floating kidney there are attacks (simulating gastralgia or renal
colic) characterized by severe abdominal pain, chills, nausea, vomiting,
fever, and collapse. Scarcely any mention is made of such symptoms,
which were first described by Dietl in 18G4, and a more wide-spread knowl-
edge of their occurrence in connection with this condition is desirable.
My attention was called to them in 1880 by Palmer Howard in the case
of a stout lady, who suffered repeatedly with the most severe attacks
of abdominal pain and vomiting, which constantly required morphia. A
720 DISEASES OF THE KIDNEYS.
tumor was discovered a little to the right of the navel, and the diag-
nosis of probable neoplasm was concurred in by Flint (Sr.) and Gaillard
Thomas. The patient lost weight rapidly, became emaciated, and in the
spring of 1881 again went to New York, where she saw Van Buren, who
diagnosed a floating kidney and said that these paroxysms were asso-
ciated with it in a gouty person. He cut off all stimulants, reassured the
lady that she had no cancer, and from that time she rapidly recovered,
and the attacks have been few and far between. In this patient any over-
indulgence in eating or in drinking is still liable to be followed by a very
severe attack. These attacks may also be mistaken for renal colic, and
the operation of nephrotomy has been performed.
In other instances the attacks of pain may be thought to be due to in-
testinal disease or to recurring appendicitis. The cause of these parox-
ysmal attacks is not quite clear. Dietl thought they were due to strangu-
lation of the kidney or to twists or kinks in the renal vessels due to the
extreme mobility. During the attacks the urine is sometimes high-colored
and contains an excess of uric acid or of the oxalates. It is stated, too,
that blood or pus may be present. The kidney may be tender, swollen,
and less freely movable. Intermittent hydronephrosis has sometimes
been associated with movable kidney.
The diagnosis is rarely doubtful, as the shape of the organ is usually
distinctive and the mobility marked. Tumors of the gall-bladder, ovarian
growths, and tumors of the bowels may in rare instances be confounded
with it.
Treatment. — The kidney has been extirpated in many instances,
but the operation is not witliout risk, and there have been several fatal
cases. Stitching of the kidney — nephrorrhaphy — as recommended by Hahn,
is the most suitable procedure, and statistics recently published by Keen
show that relief is afforded in many cas3s by the procedure. It does not,
however, always succeed.
The treatment by trusses and bandages is not satisfactory, though
great relief is sometimes obtained. As a rule, bandages, with pads press-
ing to the right of the navel, are not well borne, as the kidney is often
sensitive. In some instances, however, the greatest relief is experi-
enced by this procedure. An air-pad beneath the bandage, as recom-
mended by Newman, is probably the best. In other cases a broad bandage
well padded in the lower abdominal zone pushes up the intestines and
makes them act as a support. In the attacks of severe colic morphia is
required. When dependent, as seems sometimes the case, upon an excess
of uric acid or the oxalates, the diet must be carefully regulated.
CIRCULATORY DISTURBANCES. 721
II. CIRCULATORY DISTURBANCES.
Normally the secretion of urine is accomplished by the maintenance
of a certain blood-pressure within the glomeruli and by the activity of
the renal epithelium. Bowman's views on this question have been gen-
erally accepted, and the watery elements are held to be filtered from the
glomeruli ; the amount depending on the rapidity and the pressure of the
blood current ; the quality, whether normal or abnormal, depending upon
the integrity of the capillary and glomerular epithelium ; while the greater
portion of the solid ingredients are excreted by the epithelium of the con-
voluted tubules. The integrity of the epithelium covering the capillary
tufts within Bowman's capsule is essential to the production of a normal
urine. If under any circumstances their nutrition fails, as when, for
example, the rapidity of the blood-current is lowered, so that they are
deprived of the necessary amount of ox3'gen, the material which filters
through is no longer normal (i. e., water), but contains serum albumen.
Cohnheim has shown that the renal epithelium is extremely sensitive to
circulatory changes, and that compression of the renal artery for only a
few minutes causes serious disturbance.
The circulation of the kidney is remarkably influenced by reflex
stimuli coming from the skin. Exposure to cold causes heightened
blood-pressure within the kidneys and increased secretion of urine. So
also in the chills of malaria, after which a large amount of pale urine
may be passed.
Congestion of the Kidneys. — (1) Active Congestion; Hypermmia. —
Acute congestion of the kidney is met with in the early stage of nephritis,
whether due to cold or to the action of poisons and severe irritants.
Turpentine, cubebs, cantharides, and copaiba are all stated to cause ex-
treme hyperaemia of the organ. The most typical congestion of the
kidney which we see post mortem is that in the early stage of acute
Bright's disease, when the organ may be large, soft, of a dark color, and
on section blood drips from it freely.
It has been held that in all the acute fevers the kidneys are congested,
and that this explained the scanty, high-colored, and often albuminous
urine. On the other hand, by Koy's oncometer, Walter Mendelson has
shown that the kidney in acute fever is in a state of extreme anaemia,
small, pale, and bloodless; and that this anaemia, increasing with the
pyrexia and interfering with the nutrition of the glomerular epithelium,
accounts for the scanty, dark-colored urine of fever and for the presence
of albumen. In the prolonged fevers, however, it is probable that relaxa-
tion of the arteries again takes place. Certainly it is rare to find post
mortem such a condition of the kidney as is described by Mendelson. On
the contrary, the kidney of fever is commonly swollen, the blood-vessels
are congested, and the cortex frequently shows traces of cloudy swelling.
However, the circulatory disturbances in acute fevers are probably less im-
722 DISEASES OF THE KIDNEYS.
portant than the irritative effects of either the specific agents of the dis-
ease or the products produced in their growth, or in the altered metabolism
of the tissues. The urine is diminished in amount, and may contain
albumen and tube-casts.
(2) Passive Congestion ; Meclia^iical Hypermmia. — This is found in
cases of chronic disease of the heart or lung, with impeded circulation,
and as a result of pressure upon the renal veins by tumors, the pregnant
uterus, or ascitic fluid In the cardiac kidney, as it is called, the cyanotic
induration associated with chronic heart-disease, the organs are enlarged
and firm, the capsule strips off, as a rule, readily, the cortex is of a deep
red color, and the pyramids of a purple red. The section is coarse-look-
ing, the substance is very firm, and resists cutting and tearing. The in-
terstitial tissue is increased, and there is a small celled infiltration be-
tween the tubules. Here and there the Malpighian tufts have become
sclerosed. The blood-vessels are usually thickened, and there may be
more or less granular, fatty, or hyaline changes in the epithelium of the
tubules. The condition is indeed a diffuse nephritis. The urine is usu-
ally reduced, is of high specific gravity, and contains more or less albu-
men. Hyaline tube-casts and blood-corpuscles are not uncommon. In
uncomplicated cases of the cyanotic induration uraemia is rare. On the
other hand, in the cardiac cases with extensive arterio-sclerosis, the kidneys
are more involved and the renal function is likely to be disturbed.
III. ANOMALIES OF THE URINARY SECRETION.
1. HiEMATURIA.
The following division may be made of the causes of haematuria :
(1) General Diseases. — The malignant forms of the acute specific
fevers, such as small-pox, malaria, yellow fever, etc. ; scurvy, purpura,
and haemophilia. Occasionally in leukaemia haematuria occurs.
(2) Renal Causes. — Acute congestion and inflammation, as in Bright's
disease, or the effect of toxic agents, such as turpentine, carbolic acid, and
cantharides. When the carbolic spray was in use many surgeons suffered
from haematuria in consequence of this poison. Renal infarction, as in
ulcerative endocarditis. New growths, in which tlie bleeding is usually
profuse. Tubercle rarely causes haematuria, though at the onset, when
the papillae are involved, there may be bleeding. Stone in the kidney is a
frequent cause. Parasites: T\\q filar ia sanguinis liominis and i\\Q Bil-
harzia cause a form of haematuria met with in the tropics. The echino-
coccus is rarely associated with haemorrhage.
(3) Affections of the Urinary Passages. — Stone in the ureter, malig-
nant disease or ulceration of the bladder, the presence of a calculus, para-
sites, and, very rarely, ruptured veins in the bladder. Bleeding from the
ANOMALIES OF THE URINARY SECRETION. 723
urethra occasionally occurs in gonorrhoea and as a result of the lodgment
of a calculus.
(4) Traumatism. — Injuries may produce bleeding from any part of
the urinary passages. By a fall or blow on the back the kidney may be
ruptured, and this may be followed by very free bleeding ; less commonly
the blood comes from injury of the bladder or of the prostate. Blood
from the urethra is frequently due to injury by the passage of a catheter,
or sometimes to falls or blows.
And, lastly, there are cases in which haematuria occurs for a long time
without discoverable cause, particularly in young persons. The health
may not be seriously impaired. Gull has characterized, in a happy way, a
case of this kind as one of renal epistaxis.
Of special interest is the malarial haematuria which prevails in certain
districts and has already been considered in the section on paludism.
The diagnosis of haematuria is usually easy. The color of the urine
varies from a light smoky to a bright red, or it may have a dark porter
color. Examined with the microscope, the blood-corjDuscles are readily
recognized, either plainly visible and retaining their color, in which case
they are usually crenated, or simply as shadows. In ammoniacal urine or
urines of low specific gravity the haemoglobin is rapidly dissolved from the
corpuscles, but in normal urine they remain for many hours unchanged.
Other tests are rarely necessary. The guaiacum test consists of the
addition to the urine, in a test-tube, of a drop or two of the tincture of
guaiacum and two minims of ozonic ether. A blue color forms at the line
of contact of the two fluids and diffuses itself through the ether.
The spectroscopical examination of the urine may show either the sin-
gle band of reduced haemoglobin or the double band of oxyhaemoglobin
between the lines D and E.
It is important to distinguish between blood coming from the bladder
and from the kidneys, though this is not always easy. From the bladder
the blood may be found only with the last portions of urine, or only at the
termination of micturition. In haemorrhage from the kidneys, the blood
and urine are intimately mixed. Clots are more commonly found in the
blood from the kidneys, and may form moulds of the pelvis or of the ureter.
Wlien the seat of the bleeding is in the bladder, on washing out this organ,
the water is more or less blood-tinged ; but if the source of the bleeding is
higher, the water comes away clear. In many instances it is difficult to
settle the question by the examination of the urine alone, and the symp-
toms and the physical signs must also be taken into account.
2. HEMOGLOBINURIA.
This condition is characterized ])y the presence of blood-pigment in
the urine. The blood-cells are either absent or in insignificant numbers.
The coloring matter is not haematin, as indicated by the old name, hwma-
46
724: DISEASES OF THE KIDNEYS.
tinuria^ nor in reality always haemoglobin, but it is most frequently methae-
moglobin. The urine has a red or brownish-red, sometimes quite black
color, and usually deposits a very heavy brownish sediment. When the
haemoglobin occurs only in small quantities, it may give a lake or smoky
color to the urine. Microscopical examination shows the presence of
granular pigment, sometimes fragments of blood-disks, epithelium, and
very often darkly pigmented urates. The urine is also albuminous. The
number of red blood-corpuscles bears no proportion whatever to the in-
tensity of the color of the urine. Examined spectroscopically, there are
either the two absorption bands of oxyhaemoglobin, which is rare, or, more
commonly, there are the three absorption bands of methaemoglobin, of
which the one in the red near C is characteristic. Two clinical groups
may be distinguished.
(1) Toxic HsBinoglobinuria. — This is caused by poisons which produce
rapid dissolution of the blood-corpuscles, such as chlorate of potash in large
doses, pyrogallic acid, carbolic acid, arseniuretted hydrogen, carbon diox-
ide, naphthol, and muscarine ; also the poisons of scarlet fever, yellow fever,
typhoid fever, malaria, and syphilis. It has also followed severe burns. Ex-
posure to excessive cold and violent muscular exertion are stated to produce
haemoglobinuria. A most remarkable toxic form occurs in horses, com-
ing on with great suddenness and associated with paresis of the hind legs.
Death may occur in a few hours or a few days. Horses are attacked only
after being stalled for some days and then taken out and driven, particu-
larly in cold weather. The affection is common in horses in this country.
The form of haemoglobinuria from cold and exertion is extremely rare
No instance of it, even in association with frost-bites, came under my ob-
servation in Canada. Blood transfused from one mammal into another
causes dissolution of the corpuscles with the production of haemoglobinu-
ria ; and, lastly, there is the epidemic hcamoglohinuria of the new-born,
associated with jaundice, cyanosis, and nervous symptoms.
(2) Paroxysmal Hsemoglobinuria. — This rare disease is characterized
by the occasional passage of bloody urine, in which the coloring matter
only is present. It is more frequent in males than in females, and occurs
chiefly in adults. It seems specially associated with cold and exertion,
and has often been brought on, in a susceptible person, by the use of a
cold foot-bath. Paroxysmal haemoglobinuria has been found, too, in per-
sons subject to the various forms of Raynaud's disease. Many regard the
relation between these two affections as extremely close ; some hold that
they are manifestations of one and the same disorder. Druitt, the author
of the well-known Surgical Vade-mecum, has given a graphic description
of his sufferings, which lasted for many years, and were accompanied
with local asphyxia and local syncope. The connection, however, is not
very common. In only one of the cases of Raynaud's disease which I
have seen was paroxysmal haemoglobinuria present, and in it epileptic
attacks occurred at the same time. The relation of the disease to
ANOMALIES OF THE URINARY SECRETION. 725
malaria is not so close as has been thought by many writers. No doubt it
has been frequently confounded with a malarial haimaturia. The attacks
may come on suddenly after exposure to cold or as a result of mental or
bodily exhaustion. They may be preceded by chills and pyrexia. In other
instances the temperature is subnoi*mal. There may be vomiting and
diarrhea. Pain in the lumbar region is not uncommon. The haemo-
globinuria rarely persists for more than a day or two — sometimes, indeed,
not for a day. There are instances in which, even in the course of a sin-
gle day, there have been two or three paroxysms, and in the intervals clear
urine has been passed. Jaundice has been present in a number of cases.
According to Ealfe, paroxysmal hsemoglobinuria may alternate with gen-
eral symptoms of the same character, but associated only with the passage
of albumen and an increased quantity of urea in the urine. In such cases
he supposes that the toxic agent, whatever its nature, has destroyed only
a limited number of the corpuscles, the coloring matter of which is readily
dealt with by the spleen and liver, while the globulin is excreted in the
urine. The cases are rarely if ever fatal.
The essential pathology of the disease is unknown, and it is difficult
to form a theory which will meet all the facts — particularly the relation
with Eaynaud's disease, which is rightly regarded as a vaso-motor disorder.
Increased haemolysis and dissolution of the haemoglobin in the blood-serum
(haemoglobinaemia) precedes, in each instance, the appearance of the color-
ing matter in the urine ; but, as Ponfick has shown, the amount of free
haemoglobin must reach a certain grade before it is excreted.
Treatment. — In all forms of haematuria rest is essential. In that
produced by renal calculi the recumbent posture may suffice to check
the bleeding. Full doses of acetate of lead and opium should be tried,
then ergot, gallic and tannic acid, and the dilute sulphuric acid. The
oil of turpentine, which is sometimes recommended, is a risky remedy
in haematuria. Extr. hamamelis virgin, and extr. hydrastis canad. are
also recommended. Cold may be applied to the loins or dry cups in the
lumbar region.
The treatment of haemoglobinuria is unsatisfactory. Nothing seems
to check the occurrence of the attacks. During the paroxysm the patient
should be kept warm and given hot drinks. Quinine is recommended in
large doses, on the supposition — as yet unwarranted — that the disease is
specially connected with malaria. If there is a syphilitic history iodide
of potassium, in full doses, may be tried. In a warm climate the attacks
are much less frequent.
III. Albumtkuria.
The presence of albumen in the urine, formerly regarded as indicative
of Bright's disease, is now recognized as occurring under many circum-
stances without the existence of serious organic change in the kidney.
726 DISEASES OF THE KIDNEYS.
Two groups of cases may be recognized — those in which the kidneys show
no coarse lesions, and those in which there are evident anatomical
changes.
Albuminuria without Coarse Renal Lesions.— («) Functional, So-
called Physiological, Albuminuria. — In a normal condition of the kidney
only the water and the salts are allowed to pass from the blood. When
albuminous substances transude there is probably disturbance in the nu-
trition of the epithelium of the capillaries of the tuft, or of the cells sur-
rounding the glomerulus. This statement is still, however, in dispute,
and Senator, Grainger Stewart, and others hold that there is a physiologi-
cal albuminuria which may follow muscular work, the ingestion of food
rich in albumen, violent emotions, cold bathing, and dyspepsia. The dif-
ferences of opinion on this point are striking, and observers of equal
thoroughness and reliability have arrived at directly opposite conclusions.
The presence of albumen in the urine, in any form and under any cir-
cumstance, may be regarded as indicative of change in the renal or glom-
erular epithelium, a change, however, which may be transient, slight,
and unimportant, depending upon variations in the circulation or upon
the irritating effects of substances taken with the food or temporarily
present, as in febrile states.
Much attention has been given of late years to the albuminuria of
adolescence, or cyclic albuminuria, which is also believed to be a func-
tional disorder. A majority of the cases occur in young persons — boys
more commonly than girls — and the condition is often discovered accident-
ally. The urine, as a rule, contains only a very small quantity of albu-
men, but in some instances large quantities are present. The most strik-
ing feature is the variability. It may be absent in the morning and only
present after exertion, or it may be greatly increased after taking food,
particularly proteids. The quantity of urine may be but little if at all in-
creased, the specific gravity is usually normal, and the color may be high.
Occasionally, hyaline casts may be found, and in some instances there
has been transient glycosuria. As a rule, the pulse is not of high tension
and the second aortic sound is not accentuated.
Various forms of this affection have been recognized by writers, such
as neurotic, dietetic, cyclic, intermittent, and paroxysmal — names which
indicate the characters of the different varieties. A large proportion of
the cases get well after the condition has persisted for a variable period.
This in itself is an evidence that the changes, whatever their nature,
were transient and slight. In these instances tlie albumen exists in small
quantity, tube-casts are not present, and the arterial tension is not in-
creased. In a second group the albumen is more persistent, the amount
is larger, though it may vary from day to day, and the pulse tension is
increased. In such instances the persistent albuminuria probably indi-
cates actual organic change in the kidney.
{b) Febrile Albuminuria. — Pyrexia, by whatever cause produced,
ANOMALIES OF THE URINARY SECRETION. 727
may cause slight albuminuria. The presence of the albumen is due to
slight changes in the glomeruli induced by the fever, such as cloudy swell-
ing, which cannot be regarded as an organic lesion. It is extremely
common, occurring in pneumonia, diphtheria, typhoid fever, and even in
the fever of acute tonsillitis. The amount of albumen is slight, .and it
usually disappears from the urine with the cessation of the fever.
(c) Hcemic Changes. — Purpura, scurvy, chronic poisoning by lead or
mercury, syphilis, leukaemia, and profound anaemia may be associated with
slight albuminuria. Abnormal ingredients in the blood, such as bile-
pigment and sugar, may cause the passage of small amounts of albu-
men.
The transient albuminuria of pregnancy may belong to this haemic
group, although in a majority of such cases there are changes in the renal
tissue. Albumen may be found sometimes after the inhalation of ether or
chloroform.
{d) Albuminuria occurs in certain affections of the nervous system.
This so-called neurotic albuminuria is seen after an epileptic seizure and
in apoplexy, tetanus, exophthalmic goitre, and injuries of the head.
Albuminuria with Definite Lesions of the Urinary Organs. — {a) Con-
gestion of the kidney, either active, such as follows exposure to cold and
is associated with the early stages of nephritis, or passive, due to obstructed
outflow in disease of the heart or lungs, or to pressure on the renal veins
by the pregnant uterus or tumors.
{b) Organic disease of the kidneys — acute and chronic Bright's disease,
amyloid and fatty degeneration, suppurative nephritis, and tumors.
(c) Affections of the pelvis, ureters, and bladder, when associated with
the formation of pus.
Tests for Albumen. — Both morning and evening urine should be
examined, and in doubtful cases at least three specimens. If turbid, the
urine should be filtered, though turbidity from the urates is of no moment,
since it disappears at once on the application of heat.
Heat and Nitric-acid Test. — The urine is boiled in a test-tube over a
spirit-lamp, and a drop of nitric acid is then added. If a cloudiness occurs
on boiling, it maybe due to phosphates, which are dissolved on the addition
of an acid. Persistence of the cloudiness indicates albumen.
Heller'' s Test. — A small quantity of faming nitric acid is poured into the
test-tube, and with a pipette the urine is allowed to flow gently down the
side upon the acid. At the line of junction of the two fluids, if albumen
is present, a white ring is formed. This contact method is trustworthy,
and, for the routine clinical work, is probably the most satisfactory. A
diffused haze, due to mucin, is sometimes seen just above the white ring
of albumen. A colored ring at the junction of the acid and the urine is
due to the oxidation of the coloring matters in the urine.
Sir William Roberts strongly recommends the magnesium-nitric test.
One volume of strong nitric acid is mixed with five volumes of the saturated
728 DISEASES OF THE KIDNEYS.
solution of sulphate of magnesium. This is used in the same way as the
nitric acid in Heller's test.
Picric acid, introduced by George Johnson, is a delicate and useful
test for albumen. A saturated solution is used and employed as in the
contact method. It has been urged against this test that it throws down
the mucin, peptones, and certain vegetable alkaloids, but these are dissolved
by heat.
For minute traces of albumen the trichloracetic acid may be used, or
Millard's fluid, which is extremely delicate and consists of glacial carbolic
acid (ninety-five per cent), 2 drachms ; pure acetic acid, 7 drachms ; liquor
potassae, 2 ounces 6 drachms.
A quantitative estimate of the albumen can be made by means of Es-
bach's tube, but the rough method of heating and boiling a certain quantity
of acidulated urine in a test-tube and allowing it to stand, is often em-
ployed. The depth of deposit can then be compared with the whole
amount of urine, and the proportion is expressed as a mere trace, almost
solid, one fourth, one half, and so on. This, of course, does not give an
accurate indication of the proportion of albumen in the total quantity of
urine. For the more elaborate methods the reader is referred to the works
on urinalysis.
The above tests refer entirely to serum albumen. Other albuminous
substances occur, such as serum globulin, peptones, and hemialbumose. By
saturating the urine with magnesium sulphate, the globulin is precipitated,
coagulated, and then readily separated from the serum albumen.
Traces of peptones are found in the urine in many acute diseases and
in chronic suppuration. They are not precipitated by heat or nitric acid,
but are thrown down by picric acid and dissolved by heat. If the urine
contains peptones, a rose or pinkish tint is formed at the junction of the
two fluids when urine is allowed to flow gently into a test-tube containing
Fehling's solution. Peptonuria has no clinical significance.
Propepton, or hemialbumose, is not of any practical importance. It
was found by Bence- Jones in the urine in osteomalacia, and occurs oc-
casionally in other affections.
Prognosis. — This depends, of course, entirely upon the cause. Fe-
brile albuminuria is transient, and in a majority of the cases depending
upon ha3mic causes the condition disappears and leaves the kidneys in-
tact. An occasional trace of albumen in a man over forty, with or with-
out a few hyaline casts, and with increased tension and thick vessel walls,
usually indicates changes in the kidneys. The persistence of a slight
amount of albumen in young men without increased arterial tension is
less serious as even after continuing for years it may disappear. I have
already spoken of the outlook in the so-called cyclic albuminuria.
Practically in all cases the presence of albumen indicates a change of
some sort in the glomeruli, the nature, extent, and gravity of Avhich it is
difficult to estimate, so that other considerations, such as the presence of
ANOMALIES OF TFIE URINARY SECRETION. 729
tube-casts, the existence of increased tension, the general condition of the
patient, and the influence of digestion upon the albumen, must be care-
fully considered.
The physician is daily consulted as to the relation of albuminuria and
life assurance. As liis function is to protect the interests of the company,
he should reject all cases in which albumen occurs in the urine. It is
even doubtful if an exception should be made in young persons with
transient albuminuria. Naturally, companies lay great stress upon the
presence or absence of albumen, but in the most serious and fatal malady
with which they have to deal, chronic interstitial nephritis, the albumen is
often absent or transient, even when the disease is well developed. After
the fortieth year, from a standpoint of life insurance, the state of the
arteries is far more important than the condition of the urine.
IV. Pyukia [Pus in the Urine).
Causes. — (1) Pyelitis and Pyelonephritis. — In large abscesses of the
kidney, pyonephrosis, the pus may be intermittent, and for days or even
weeks the urine is free. In calculous and tuberculous pyelitis the pyuria
is usually continuous, though varying in intensity. In these cases, as a
rule, the pus is mixed with the urine, which is acid in reaction. In the
early stages of pyelitis the transitional epithelium may be abundant, but
is not in any way distinctive. In the pyelitis and pyelonephritis following
cystitis the urine is usually alkaline, and contains more mucus ; micturi-
tion is usually more frequent, and the history points to a previous bladder
affection.
(2) Cystitis. — The urine is alkaline, often fetid, the pus ropy, and
the amount of urine greatly increased. The ropy, thick mucus usually
comes with the last portions of the urine. Triple phosphate crystals may
be present in the freshly passed urine.
(3) Urethritis^ particularly gonorrhoea. The pus appears first, is in
small quantities, and there are signs of local inflammation.
(4) In leucorrhoea the quantity of pus is usually small, and large flakes
of vaginal epithelium are numerous. In doubtful cases, when leucorrhoea
is present, the urine should be withdrawn by a catheter.
(5) Rupture of Abscesses into the Urinary Passages. — In such cases
as pelvic or perityphlitic abscess there have been previous symptoms of
pus formation. A large amount is passed within a short time, then the
discharge stops abruptly or rapidly diminishes within a few days.
Pus gives to the urine a white or yellowish-white appearance. On
settling ther(! is a heavy grayish sediment, and the supernatant fluid is
usually turbid, '^^riie sediment is often tenacious and ropy. The reaction
is generally alkaline, and the odor may be ammoniacal even when passed.
Examination with the microscope reveals the presence of a large number
<)f pus-corpuscles, which are usually, when the pus comes from the blad-
730 DISEASES OF THE KIDNEYS.
der, well formed ; the protoplasm is granular, and often shows many
translucent processes.
The only sediment likely to be confounded with pus is that of the
phospluites ; but it is whiter and less dense, and is distinguished immedi-
ately by microscopical exjimination.
With the pus there is always more or less epithelium from the bladder
and pelvis, but since in these situations the forms of cells are practically
identical, they afford no information as to the locality from which the pus
has come.
The treatment of pus in the urine is considered under the conditions
in which it occurs.
V. Chyluria — Non-parasitic.
This is a rare affection, occurring in temperate regions and unassoci-
ated with the filaria Jiominis sanguinis. The urine is of an opaque white
color ; it resembles milk closely, is occasionally mixed with blood (haemato-
chyluria), and sometimes coagulates into a firm, jelly-like mass. In other
instances there is at the bottom of the vessel a loose clot which may be
distinctly blood-tinged. Under the microscope the turbidity seems to be
caused by numerous minute granules — more rarely oil droplets similar to
those of milk. Traces of albumen are usually present. The amount of
urine passed is generally increased, and the chylous condition is intermit-
tent. It may persist for years without deterioration of health or evidence
of serious disease.
Since the discovery of the Jilaria homiiiis sanguinis it has been incor-
rectly held by some that all of the cases of chyluria are of this parasitic
nature. I had an opportunity in Montreal of making a careful study of a
French-Canadian woman, a patient of J. B. McConnell's, who had had
chyluria for more than thirteen years. The urine was quite milky in
color and occasionally mixed with blood. Neither ova nor embryos were
found in the urine or in the blood examined at night. After her death
I was enabled to make a thorough dissection of the abdominal lymph
vessels, which were found perfectly normal. The thoracic duct was not
enlarged, the renal lymphatics were not distended ; the kidneys were in-
creased in size, but showed no special changes. The most careful exami-
nation of the lymph glands and vessels failed to reveal the presence of
parasites.
The pathology of the condition is unknown. No known remedies have
any influence upon the chyluria.
(For parasitic chyluria see Filariasis.)
VI. liTTFiriiiA (Lithwmia; Lithic-acid Diathesis).
The amount of uric acid excreted daily depends greatly upon the diet,
ranging from lialf a gramme on a vegetable to as high, even, as two
ANOMALIES OF THE URINARY SECRETION. Y31
grammes on an animal diet. In the urine of herbivora it occurs only in
traces. In that of carnivora it may be absent altogether. On the other
hand, in the urine of birds and reptiles it is the chief nitrogenous ingre-
dient. As Sir William Roberts remarks, its presence in the human urine
is somewhat of an anomaly, as its place is very much better taken by urea,
which is easily soluble and better adapted to the mammalian plan of a
liquid urine. He regards it as a sort of vestigial remnant.
Place and Mode of Formation of the Uric Acid. — It is now very gen-
erally conceded that uric acid is formed in the tissues and excreted by the
kidneys. It may occur in traces in the blood even in health. Von Jaksch,
who has recently examined the blood of 109 individuals, found no trace in
9 healthy persons, nor was it present in cases of typhoid fever or in nerv-
ous affections or in diseases of the liver and gastro-intestinal canal, except
when anaemia coexisted. On the other hand, it was present in connection
with all those diseased processes in ^vhich oxidation was disturbed, either
directly, as in affections of the lungs, such as pneumonia, or indirectly, as
in anaemia, in which the oxygen-carriers are deficient. According to
Haig, the amount in the blood rises and falls with the degree of alkalinity
(as more is held in solution), and all circumstances which increase this are
associated with an increase in the amount of uric acid.
As to the place of formation, the experimental evidence points strongly
to the liver, and, according to Minkow^ski, it is formed there by the synthe-
sis of ammonia and lactic acid. The views, however, as to its place of
production and the antecedents are by no means harmonious. Garrod
still holds that the kidneys are concerned not only with its excretion, but
with its formation. On the other hand, Ebstein thinks that it is chiefly
produced in the muscles and in the bone marrow. Nor is it yet settled
whether uric acid is only an intermediate step in the formation of urea or
whether it has an independent origin.
Mode of Elimination. — Uric acid is extremely insoluble, a gramme re-
quiring for its solution, at ordinary temperature, fourteen litres of water,
and about half that amount at body temperature. In the 1,500 to 2,000
0. c. of urine passed in the day the uric acid could not be dissolved, but it
is eliminated in combination as soluble salts, chiefly as urates of ammonium
and sodium. The power in the blood of holding the uric acid in solution
depends upon the degree of alkalinity ; thus it lias been long known that
the excretion of uric acid some hours after breakfast is high. This is in
what Sir William Roberts calls " the alkaline tide." Ilaig has shown that
this excretion can be increased or diminished by increasing or diminishing
the alkalinity of the blood ; thus, under salicylate of soda, given in fifteen
grain doses tliree times a day, the excretion of the uric acid is increased
on the first and second days, and subsequently falls to the normal amount.
He explains this by supposing that the salicylate finds a considerable
quantity of uric acid stored in the liver, spleen, and other tissues, gets this
into solution, and the greater part of it is passed in the urine. His obser-
732 DISEASES OP THE KIDNEYS.
vations indicate that alkalies, such as the phosphate of soda and com-
pounds of salicylic acid, increase markedly the excretion of this ingredient
in the urine, and also increase the amount of it in the blood, withdrawing
it from the spleen and liver. On the other hand, acids, lead, and iron in-
terfere with the solubility of the uric acid and with its elimination. A fact
of great practical importance which he mentions is that lithia, " though a
beautiful solvent of uric acid in a test-tube, yet when given to the human
subject by mouth never reaches the uric acid at all, because it at once
forms an insoluble compound with the phosphate of soda in the blood,
thus removing from that fluid one of the natural solvents of uric acid,
and diminishing its powder of holding uric acid in solution." This is
directly opposed to the prevalent ideas of the value of the lithia compounds
in the uric-acid diathesis.
The pathology of uric acid is more a matter of defective elimination
than of excessive formation. In conditions of the system associated w^ith
persistent diminished alkalinity of the blood the uric acid accumulates in
the liver, spleen, and the joints. The degree of alkalinity of the kidney
structure possibly, as Haig suggests, may have an influence in determin-
ing how much shall be excreted and how much retained, and, according to
his views, it is this small remnant or overflow which accumulates in the
blood and produces headache, high tension of the pulse, and mental de-
pression, and when deposited in the joints causes gouty arthritis and the
uratic lesions.
Occurrence in ilie Urine. — The uric acid occurs in combination chiefly
with ammonium and sodium, forming the acid urates. In smaller quan-
tities are the potassium, calcium, and lithium salts. The uric acid may
be separated from its bases and crystallizes in rhombs or prisms, which
are usually of a deep red color, owing to the staining of the urinary pig-
ments. The sediment formed is granular and the groups of crystals look
like grains of Cayenne pepper. It is very important not to mistake a de-
posit of uric acid for an excess. The deposition of numerous grains in
the urine within a few hours after passing is more likely to be due to con-
ditions which diminish the solvent power than to increase in the quantity.
Of the conditions which cause precipitation of the uric acid Koberts gives
the following : "(1) High acidity ; (2) poverty in mineral salts ; (3) low
pigmentation; and (4) high percentage of uric acid." The grade of
acidity is probably the most important element.
More common is the precipitation of amorphous urates, forming the
so-called brick-dust or lateritious deposit, which has a pinkish color, due
to the presence of urinary pigment. It is composed chiefly of the acid
sodium urates. It occurs particularly in very acid urine of a high specific
gravity. As the urates are more soluble in warm solutions they frequently
deposit as the urine cools. Here, too, the deposition does not necessarily,
indeed usually does not, mean an excessive excretion, but the existence of
conditions favoring the deposit.
ANOMALIES OP THE URINARY SECRETION. 733
Murchison introduced the term lithaemia to designate certain symptoms
due, as he supposed, to functional disturbance of the liver. Not only have
his views been widely adopted, but, as is so often the case when we give
the rein to theoretical conceptions of disease, the so-called manifestations
of this state have so multiplied that some authors attribute to this cause a
considerable proportion of the ailments affecting the various systems of the
body. Thus one writer enumerates not fewer then thirty-nine separate
morbid conditions associated with lithaemia. From what has been said as
to our knowledge, or rather our lack of knowledge, of the mode of forma-
tion and elimination of uric acid it is very evident that the physiology of
the subject must be widely extended before we are in a position to draw
safe conclusions. Thus it is by no means sure that, as Murchison sup-
posed, the essential defect is in a functional disorder of the liver, disturb-
ing the metabolism of the albuminous ingredients, nor is it at all certain
that the only offending substance is uric acid. Bouchard contends that
the so-called lithiasis has little or nothing to do with disturbance in the
function of the liver, and that it has not been shown that uric acid is the
only or even the chief agent in producing the symptoms. In the present
imperfect state of knowledge it is impossible with any clearness to define
the pathology of the so-called uric-acid diathesis. AVe may say that cer-
tain symptoms arise in connection with defective food or tissue metabolism,
more particularly of the nitrogenous elements. Deficient oxidation is
probably the most essential factor in the process, with the result of the
formation of less readily soluble and less readily eliminated products of
retrograde metamorphosis. This faulty metabolism if long continued
may lead to gout, with uratic deposits in the joints, acute inflammations,
and arterial and renal disease. In a large group of cases the disturbed
metabolism produces high tension in the arteries (probably as a direct
sequence of interference with the capillary circulation) and ultimately
degenerations in various tissues, particularly the scleroses.
Overeating and overdrinking, when combined with deficient muscular
exercise, lie at the basis of this nutritional disturbance. The symptoms
which are believed to characterize the uric-acid diathesis have already
been briefly considered under the section on irregular gout, and the ques-
tion of diet and exercise has also been there considered.
VII. OXALURIA.
Oxalic acid occurs in the urine, in combination with lime, forming an
oxalate which is held in solution by the acid phosphate of soda. About
.01 to .02 gramme is excreted in the day. It never forms a heavy deposit,
but the crystals— usually octahedra, rarely dumb-bell-shaped— collect in the
mucus-cloud and on the sides of the vessel. The amount varies extremely
with the diet, and it is increased largely when such fruits and vegetables
as tomatoes and rhubarb are taken. It is also a product of incomplete oxi-
734 DISEASES OP THE KIDNEYS.
dation of the organic substances in the body, and in conditions of increased
metabolism the amount in the urine becomes larger. It is stated also to
result from the acid fermentation of the mucus in the urinary passages
and the crystals are usually abundant in spermatorrhoea.
When in excess and present for any considerable time, the condition is
known as oxaluria, the chief interest of which is in the fact that the crys-
tals may be deposited before the urine is voided, and form a calculus.
It is held by many that there is a special diathesis associated with
this state and manifested clinically by dyspepsia, particularly the nervous
form, irritability, depression of spirits, lassitude, and sometimes marked
hypochondriasis. There may be in addition neuralgic pains and the gen-
eral symptoms of neurasthenia. The local and general symptoms are
probably dependent upon some disturbance of metabolism of which the
oxaluria is one of the manifestations. It is a feature also in many gouty
persons, and in the condition called lithsemia.
VIII. Cystinuria.
Cystin does not occur in normal urine. It is very rarely met with, and
its chief interest is owing to the fact that it may form a calculus. Its
presence in the urine has been determined in many members of the same
family, and the condition appears sometimes to be hereditary. As it con-
tains sulphur, it is thought to be formed from the taurin of the bile.
IX. Phosphaturia.
The phosphoric acid is excreted from the body in combination with
potassium, sodium, calcium, and magnesium, forming two classes, the alka-
line phosphates of sodium and potassium and the earthy phosphates of
lime and magnesia. ^'•The alkaline j^hosphates exist in the blood in the
form of neutral sodium and potassium phosphates (hydrogen-disodium
phosphates, HNa^POJ, but appear in the urine as acid sodium and po-
tassium phosphates (dihydrogen-sodium phosphates, H^lS^aPOJ, and
thus cause the acid reaction of that secretion. The change of the neutral
into the acid salt is caused by the decomposition effected by the act of
secretion, in which the bicarbonates and neutral phosphates in the blood
change into carbonates and acid phosphates respectively." (Ralfe.)
Of the earthy phosphates, those of lime are abundant, of magnesium
scanty. In urine which has undergone the ammoniacal fermentation,
either inside or outside the body, there is in addition the ammonio-
magnesium or triple phosphate, whicli occurs in triangular prisms or in
feathery or stellate crystals, hence the term given to this form of stellar
phosphates. The earthy phosphates occur as a sediment in the urine
when the alkalinity is due to a fixed alkali, or under certain circumstances
the deposit may take place within the bladder, and then tlie phosphates
are passed at the end of micturition as a whitish fluid, which is popularly
ANOMALIES OF THE URINARY SECRETION. 735
confounded with spermatorrhooa. The calcium phosphate may be pre-
cipitated by heat and produce a cloudiness which maybe mistaken for albu-
men, but is at once dissolved upon making the urine acid. This condition
is very frequent in persons suifering from dyspepsia or from debility of any
kind. The phosphates may be in great excess, rising in the twenty-four
hours to from 7 to 9 grammes (Tessier), whereas the normal amount is not
more than 25 grammes. And, lastly, the phosphates may be deposited in
urine which has undergone decomposition, in which the carbonate of am-
monia from the urea combines with the magnesium phosphates, forming
the triple salt. This is seen in cystitis, and is due to the introduction of
a bacterial ferment.
The clinical significance of an excess of phosphates, to which the term
phosphaturia is applied, has been much discussed. It must be remem-
bered that a deposit does not necessarily mean an excess, to determine
which a careful analysis of the twenty-four hours' secretion should be
made. It has long been thought that there is a relation between the ac-
tivity of the nerve-tissues and the output of ' phosphoric acid ; but the
question cannot yet be considered settled. The amount is increased in
wasting diseases, such as phthisis, acute yellow atrophy of the liver, leu-
kaemia, and severe anaemia, whereas it is diminished in acute diseases and
during pregnancy.
In a condition termed by Tessier, Ralfe, and others phosphatic dia-
betes there is polyuria, thirst, emaciation, and a great increase in the
excretion of phosphates, which may be as much as from seven to nine
grammes in the day. The urine is usually acid, free from sugar, the patients
are nervous ; in some instances sugar has been present in the urine, and
in others it subsequently makes its appearance.
X. In^dicanuria.
The substance in the urine which has received this name is the indoxyl-
sulphate of potassium, in which form it appears in the urine and is color-
less. When concentrated acids or strong oxidizing agents are added to
the urine, this substance is decomposed and the indigo set free. It is
present only in small quantities in healthy urine. It is derived from the
indol, a product formed in the small intestine by the decomposition of the
albumen under the influence of bacteria. When absorbed, this is oxidized
in the tissues to indoxyl, which combines with the potassium sulphate,
forming the above-named substance.
The quantity of indican is increased on a milk diet, in all wasting
diseases, and whenever any large quantities of albuminous substances are
undergoing rapid decomposition, as in the severer forms of peritonitis and
empyema. It is met with also in prolonged constipation and in ileus.
Indican has occasionally been found in calculi. Though, as a rule, the
urine is colorless when passed, there are instances in which the decompo-
736 DISEASES OF THE KIDNEYS.
sition has taken place within the body, and a blue color has been noticed
immediately after the urine was voided. Sometimes, too, in alkaline
urine on exposure there is a bluish film on the surface.
To test for indican, place four or five c. c. of nitric or hydrochloric
acid in a test-tube ; boil, and add an equal quantity of urine. A bluish
ring develops at the point of contact. Add ten c. c. of chloroform and
shake the test-tube, and on separation the chloroform has a violet or
bluish color due to the presence of indican.
XI. Melanuria.
In melanotic cancer the urine, either at the time of voiding or after
exposure to the air, may present a dark color. This pigment is known as
melanin, and it may occur in solution or in the form of small granules.
The urine may be voided clear, and subsequently, on exposure to the air
or on the addition of oxidizing substances, becomes dark. In these cases
it contains a chromogen called melanogen which turns dark by oxidation.
Von Jaksch has found that " in urine containing melanin or its precursor,
melanogen, Prussian blue is formed by adding a nitroprusside, aqueous
potash, and an acid. This reaction, however, does not seem to depend on
the presence of melanin, as it is not given by that substance when sep-
arated from the urine, but apparently by some other at present unknown
substance, which is present in traces in normal urine and is increased in
cases of melanuria, and also in those conditions where excess of indigo
occurs in the urine." (Halliburton.)
XII. Other Substances.
Fat in the urine, or lipuria, occurs, according to Halliburton, first,
without disease of the kidneys, as in excess of fat in the food, after the ad-
ministration of cod-liver oil, in fat embolism occurring after fractures, in the
fatty degeneration in phosphorus poisoning, in prolonged suppuration as in
phthisis and pyaemia, in the lip^emia of diabetes mellitus ; secondly, with
disease of the kidneys, as in the fatty stage of chronic Bright's disease, in
which fat casts are sometimes present, and, according to Ebstein, in pyo-
nephrosis ; and, thirdly, in the affection known as chyluria. The urine is
usually turbid, but there may be fat drops as well, and fatty crystals have
been found.
Lipaciduria is a term applied by von Jaksch to the condition in which
there are volatile fatty acids in the urine, such as acetic, butyric, formic,
and propionic.
Acetonuria. — Von Jaksch distinguishes the following forms of patho-
logical acetonuria : The febrile, the diabetic, the acetonuria with certain
forms of cancer, the form associated with inanition, acetonuria in psy-
choses, and the acetonuria which results from auto-intoxication. It is
doubtful, however, whether the symptoms in these are really due to the
URiEMIA. 737
acetone. It may be the substances from which this is formed, particu-
larly the diacetic acid or the oxybutyric acid. The odor of the acetone
may be marked in the breath and evident in the urine. Le Nobel's test
has been given in the section on diabetes.
Diacetic acid is probably never present in the urine in health. With
a solution of ferric chloride it gives a Burgundy-red color. A similar re-
action is given by acetic, formic, oxybutyric acids, and it may be present
in the urine of patients who are taking antipyrin, thallin, and the salicy-
lates. "If, however, the urine is previously boiled, diacetic acid, if pres-
ent, still gives the ferric-chloride reaction, but these other substances do
not. Fleischer found that the substance which gives the ferric-chloride
reaction in diabetic urine is not taken up by ether after the urine has
been acidulated with sulphuric acid, whereas ethyl-diacetic acid is solu-
ble in ether." (Halliburton.)
Alcaptonuria. — Aromatic compounds occur in the urine after the ad-
ministration of carbolic acid or gallic acid, and on exposure to air becomes
dark. In carboluria the substance causing the black color is known as
hydrochinon. Many years ago Boedeker met with cases in which the
urine became dark, owing to the presence of an aromatic compound which
he called alcapton. It has been found in cases of consumption, and in
other instances in which there are no local lesions or no general disease.
The urine may be clear on passing, and then darken on exposure to the air,
or on the addition of liquor potassse. The substance is apparently without
clinical significance except in so far as it, with the other aromatic substances,
is capable of reducing the Fehling solution, and may be mistaken for sugar.
Choluria and glycosuria have already been considered under jaundice
and diabetes.*
IV. UR^^MIA.
Under this term is grouped a series of manifestations, chiefly nervous,
developing in the course of Bright's disease, and due to the retention
within the blood of poisonous materials which should be eliminated in
the urine.
Uraemia is usually seen in nephritis, but may occur when the ureters
are obstructed, or when the circulation of blood in the kidneys is im-
peded, as in conditions of extreme engorgement following compression of
the renal vessels or in the profound alterations of the blood in cholera.
Two opposite views are held with reference to the production of
uraemia : {a) That it is due to the accumulation in the blood of excre-
mentitious material — body poisons — which should be thrown off by the
* For further details concerning the urine the student is referred to von Jaksch's
Clinical Diagnosis, Tyson on the Urine, and to Halliburton's Text-Book of Chemical
Physiology and Pathology.
738 DISEASES OF THE KIDNEYS.
kidneys. " If, however, from any cause, these organs make default, or if
there be any prolonged obstruction to the outflow of urine, accumulation
of some or of all the poisons takes place, and the characteristic symptoms
are manifested, but the accumulation may be very slow and the earlier
symptoms, corresponding to the comparatively small dose of poison, may
be very slight ; yet they are in kind, though not in degree, as indicative
of uraemia as are the more alarming, which appear towards the end, and
to which alone the name uraemia is often given." (Carter.) Several poisons
having distinct actions have been separated from the urine by Bouchard,
two of which produce convulsions, and one of which is narcotic. Bou-
chard's observations tend strongly to confirm the view now generally held,
that the symptoms are caused by the retention of the excretory products.
The nature of these poisonous ingredients is not yet known. It was for-
merly thought that the urea was the offending substance, and it has been
found increased in the blood in uraemia. Others hold that it is the accu-
mulation of carbonate of ammonia. It is more probable, however, that
there are several toxic agents at work.
(b) Traube suggested that the chief symptoms of uraemia, particularly
the coma and convulsions, were due to localized oedema of the brain. In
favor of this view is the fact that obstruction of the ureters, as by stone,
does not necessarily produce uraemia, even if long continued, and in this
obstructive suppression neither convulsions nor coma occur. Then, too,
uraemia may supervene in a case of chronic Bright's disease in which a
large amount of urine is being passed with a fair proportion of solids.
CEdema of the brain certainly does occur in some fatal cases — it may be
diffuse or localized, but it is not a constant lesion, and cannot explain all
the symptoms of uremia.
Symptoms. — Clinically, acute and chronic uraemia may be recog-
nized, but, for convenience of description, it is perhaps best to follow the
division of French writers into cerebral, dyspnoeic, and gastro-intestlnal
forms.
Among the cerebral manifestations of uraemia may be described :
{a) Mania. — This may come on abruptly in an individual who has
shown no previous indications of mental trouble, and who may not be
known to have Bright's disease. In a remarkable case of this kind which
came under my observation the patient became suddenly maniacal and
died in six days. More commonly the delirium is less violent, but the
patient is noisy, talkative, restless, and sleepless.
{b) Delusional Insanity (Folie Brightique). — Cases are by no means
uncommon, and excellent clinical reports have been issued on the subject
from several of the asylums of this country, particularly by Bremer,
Christian, and Alice Bennett. Delusions of persecution are common.
One of my cases committed suicide by jumping out of a window. The
condition is of interest medico-legally because of its bearing on testa-
mentary capacity. Profound melancholia may also supervene.
URiEMIA. 739
•
(c) Convulsions. — These may come on unexpectedly or be preceded by
pain in the head and restlessness. The attacks may be general and iden-
tical with those of ordinary epilepsy, though the initial cry may not be
present. The fits may recur rapidly, and in the interval the patient is
usually unconscious. Sometimes the temperature is elevated, but more
frequently it is depressed, and may sink rapidly after the attack. Local
or Jacksonian epilepsy may occur in most characteristic form in uraemia.
A remarkable sequence of the convulsions is blindness — urmnic amaurosis
— which may persist for several days. This, however, may occur apart
from the convulsions. It usually passes off in a day or two. There are
no ophthalmoscopic changes. Sometimes uraemic deafness supervenes,
and is probably also a cerebral manifestation. It may also occur in
connection with persistent headache, nausea, and other gastric symp-
toms.
(d) Coma. — Unconsciousness invariably accompanies the general con-
vulsions, but a coma may develop gradually without any convulsive seiz-
ures. Frequently it is preceded by headache, and the patient gradually
becomes dull and apathetic. In these cases there may have been no pre-
vious indications of renal disease, and unless the urine is examined the
nature of the case may be overlooked. Twitchings of the muscles occur,
particularly in the face and hands, but there are many cases of coma in
which the muscles are not involved. In some of these cases a condition
of torpor persists for weeks or even months. The tongue is usually furred
and the breath very foul and heavy.
(e) Local Palsies. — In the course of chronic Bright's disease hemi-
plegia or monoplegia may come on spontaneously or follow a convul-
sion, and post mortem no gross lesions of the brain be found, but only
a localized or diffused cedema. These cases, which are not very uncom-
mon, may simulate almost every form of organic paralysis of cerebral
origin.
(/) Of other cerebral symptoms, headache is important. It is most
often occipital and extends to the neck. It may be an early feature and
associated with giddiness. Other nervous symptoms of uraemia are intense
itching of the skin, numbness and tingling in the fingers, and cramps in
the muscles of the calves, particularly at night.
Urmmic dyspjima is classified by Palmer Howard as follows : (1) Con-
tinuous dyspnoea; (2) paroxysmal dyspnoea; (3) both types alternating;
and (4) Cheyne-Stokes breathing. The attacks of dyspnoea are most com-
monly nocturnal ; the patient may sit up, gasp for breath, and evince as
muf;h distress as in true asthma. Occasionally the breathing is noisy and
stridulous. The Cheyne-Stokcs type may persist for weeks, and is not
necessarily associated with coma. I have seen it in a man who travelled
over a hundred miles to consult a physician. In another instance a pa-
tient, up and about, could only when at meals feed himself in the apnoea
period. Though usually of serious omen and occurring with coma and
47
740 DISEASES OP THE KIDNEYS.
other symptoms, recovery may follow even after persistence for weeks or
even months.
The gastro-intestinal manifestations of uraemia often set in with abrupt-
ness. L'ncontroUable vomiting may come on and its cause be quite un-
recognizable. A young married woman was admitted to my wards in the
Montreal General Hospital with persistent vomiting of four or five days'
duration. The urine was slightly albuminous, but she had none of the
usual signs of uraemia, and the case was not regarded as one of Bright's
disease. The vomiting persisted and caused death. The post-mortem
showed extensive sclerosis of both kidneys. The attacks may be preceded
by nausea and may be associated with diarrhoea. In some instances the
diarrhoea may come on without the vomiting ; sometimes it is profuse and
associated with an intense catarrhal or even diphtheritic inflammation of
the colon.
A special uraemic stomatitis has been described (Barie) in w^hich the
mucosa of the lips, gums, and tongue is swollen and erythematous. The
saliva may be increased, and there is difficulty in swallowing and in mas-
tication. The tongue is usually very foul and the breath heavy and fetid.
Diagnosis. — Uraemia may be confounded with :
{a) Cerebral lesions, such as haemorrhage, meningitis, or even tumor.
In apoplexy, which is so commonly associated with kidney disease and
stiff arteries, the sudden loss of consciousness, particularly if with con-
vulsions, may simulate a uraemic attack ; but the mode of onset, the
existence of complete hemiplegia, with conjugate deviation of the eyes,
suggest haemorrhage. As already noted, there are cases of uraemic hemi-
plegia or monoplegia which cannot be separated from those of organic
lesion and which post mortem shovr no trace of coarse disease of the
brain. I know of an instance in which a consultation was held upon the
propriety of operation in a case of hemiplegia believed to be due to sub-
dural haemorrhage which post mortem was shown to be uraemic. Indeed,
in some of these cases it is quite impossible to distinguish between the
two conditions. So, too, cases of meningitis, in a condition of deep coma,
with perhaps slight fever, furred tongue, and without localizing symptoms,
may readily be confounded with uraemia.
{!)) AVitli certain infectious diseases. Uraemia may persist for weeks
or months and the patient lies in a condition of torpor or even uncon-
sciousness, with a heavily coated, perhaps dry, tongue, muscular twitchings,
a rapid feeble pulse, with slight fever. This state not unnaturally suggests
the existence of one of the infectious diseases. Cases of the kind are not
uncommon, and I have known them to be mistaken for typhoid fever and
for miliary tuberculosis.
(r) Uraemic coma may be confounded with poisoning by alcohol or
opium. In opium poisoning the pupils are contracted ; in alcoholism they
are more commonly dilated. In uraemia they are not constant ; they may
be either widely dilated or of medium size. The examination of the eye-
ACUTE BRIGHT'S DISEASE. 741
ground should be made to determine the presence or absence of albumi-
nuric retinitis. The urine should be drawn off and examined. The odor
of the breath sometimes gives an important hint.
The condition of the heart and arteries should also be taken into ac-
count. Sudden uraemic coma is more common in the chronic interstitial
nephritis. The character of the delirium in alcoholism is sometimes im-
portant, and the coma is not so deep as in uraemia or opium poisoning.
It may for a time be impossible to determine whether the condition is
due to uraemia, profound alcoholism, or haemorrhage into the pons Varolii.
The treatment will be considered under chronic Bright's disease.
V. ACUTE BRIGHT'S DISEASE.
Definition. — Acute diffuse nephritis, due to the action of cold or of
toxic agents upon the kidneys.
In all instances changes exist in the epithelial, vascular, and inter-
tubular tissues, which vary in intensity in different forms ; hence writers
have described a tubular, a glomerular, and an acute interstitial nephritis.
Delafield recognizes acute exudative and acute 'productive forms, the latter
characterized by proliferation of the connective-tissue stroma and of the
cells of the Malpighian tufts.
Etiology. — The following are the principal causes of acute ne-
phritis :
(1) Cold. Exposure to cold and wet is one of the most common causes.
It is particularly prone to follow exposure after a drinking-bout.
(2) The poisons of the specific fevers, particularly scarlet fever, less
commonly typhoid fever, measles, diphtheria, small-pox, chicken-pox,
cholera, yellow fever, meningitis, and, very rarely, dysentery. Acute nephri-
tis is not often associated with syphilis. In acute tuberculosis nephritis
is not uncommon. It may also occur in septicaemia.
(3) Toxic agents, such as turpentine, cantharides, chlorate of potash,
and carbolic acid may cause an acute congestion which sometimes ter-
minates in nephritis. Alcohol probably never excites an acute nephritis.
(4) Pregnancy, in which the condition is thought by some to result
from compression of the renal veins, although this is not yet finally settled.
The condition may in reality be due to toxic products as yet undetermined.
(5) Acute nephritis occurs occasionally in connection with extensive
lesions of the skin, as in burns or in chronic skin-diseases.
Morbid Anatomy. — The kidneys may present to the naked eye in
mild cases no evident alterations. When seen early in more severe forms
the organs are congested, swollen, dark, and the section may drip blood.
In other instances the surface is pale and mottled, the capsule strips off
readily, and the cortex is swollen, turbid, and of a grayish-red color, while
the pyramids have an intense beefy-red tint. The glomeruli in some in-
74:2 DISEASES OF THE KIDNEYS.
stances stand out plainly, deeply swollen and congested ; in other instances
they are pale.
The histology may be thus summarized : (a) Glomerular changes. In
a majority of the cases of nephritis due to toxic agents, which reach the
kidney through the blood-vessels, the tufts suffer first, and there is either
an acute intracapillary glomerulitis, in which the capillaries become filled
with cells and thrombi, or involvement of the epithelium of the tuft and
of Bow^man's capsule, the cavity of which contains leucocytes and red
blood-corpuscles. Hyaline degeneration of the contents and of the walls
of the capillaries of the tufts is an extremely common event. These pro-
cesses are perhaps best marked in scarlatinal nephritis. There may be
proliferation about Bowman's capsule. These changes interfere wdth the
circulation in the tufts and seriously influence the nutrition of the tubular
structures beyond them.
(b) The alterations in the tubular epithelium consist in cloudy swell-
ing, fatty change, and hyaline degeneration. In the convoluted tubules,
the accumulation of altered cells with leucocytes and blood-corpuscles
causes the enlargement and swelling of the organ. The epithelial cells
lose their striation, the nuclei are obscured, and hyaline droplets often
accumulate in them.
(c) Interstitial changes. In the milder forms a simple inflammatory
exudate — serum mixed with leucocytes and red blood-corpuscles — exists
between the tubules. In severer cases areas of small-celled infiltration
occur about the capsules and between the convoluted tubes. These changes
may be wide-spread and uniform throughout the organs or more intense
in certain regions.
Symptoms. — The onset is usually sudden, and when the nephritis
follows cold, dropsy may be noticed within twenty-four hours. After
fevers the onset is less abrupt, but the patient gradually becomes pale and
a puffiness of the face or swelling of the ankles is first noticed. In chil-
dren there may at the outset be convulsions. Chilliness or rigors initiate
the attack in a limited number of cases. Pain in the back, nausea, and
vomiting may be present. The fever is variable. Many cases in adults
have no rise in temperature. In young children with nephritis from cold
or scarlet fever the temperature may, for a few days, range from 101° to
103°.
The most characteristic symptoms are the urinary changes. There
may at first be suppression, more commonly the urine is scanty and
highly colored and contains blood, albumen, and tube-casts. The quantity
is reduced and only four or five ounces may be passed in the twenty-four
hours; the specific gravity is high — 1*025, or even more; the color varies
from a smoky to a deep porter color, but is seldom bright red. On stand-
ing there is a heavy deposit; microscopically there are blood-corpuscles,
epithelium from the urinary passages, and casts, hyaline, blood, and epithe-
lial in character. The albumen is abundant, forming a curdy, thick pre-
ACUTE BRIGnT'S DISEASE. Y43
cipitate. The total excretion of urea is reduced, though the percentage
is high.
Anaemia is an early and marked symptom. In cases of extensive
dropsy, effusion may take place into the pleurae and peritoaenum. 'j''here
are cases of scarlatinal nephritis in which the dropsy of the extremities is
trivial and effusion into the pleurae extensive. The lungs may become
(edematous. In rare cases there is oedema of the glottis. Epistaxis may
occur or cutaneous ecchymoses may develop in the course of the disease.
The pulse may be hard, the tension increased, and the second aortic
sound accentuated. Occasionally dilatation of the heart comes on rapidly
and may cause sudden death (Goodhart). The skin is dry and it may be
difficult to induce sweating.
Uraemic symptoms develop in a limited number of cases. They may
occur at the onset with suppression, more commonly later in the disease.
Ocular changes are not so common in acute as in chronic Bright's disease,
but haemorrhagic retinitis may occur and occasionally papillitis.
The course of acute Bright's disease varies considerably. The descrip-
tion just given is of the form which most commonly follows cold or scarlet
fever. In many of the febrile cases dropsy is not a prominent symptom,
and the diagnosis rests rather with the examination of the urine. More-
over, the condition may be transient and less serious. In other cases, as
in the acute nephritis of typhoid fever, there may be haematuria and pro-
nounced signs of interference with the renal function. The most intense
acute nephritis may exist without anasarca.
In scarlatinal nephritis, in which the glomeruli are most seriously af-
fected, suppression of the urine may be an early symptom, the dropsy is
apt to be extreme, and uraemic manifestations are common. Acute
Bright's disease in children, however, may set in very insidiously and be
associated with transient or slight (jodema, and the symptoms may point
rather to affection of the digestive system or to brain-disease.
Diagnosis. — It is very important to bear in mind that the most seri-
ous involvement of the kidneys may be manifested only by slight oedema
of tlie feet or puffiness of the eyelids, without impairment of the gen-
eral health. The first indication of trouble may be a uraemic convulsion.
This is particularly the case in the acute nephritis of pregnancy, and it is
a good rule for the practitioner, when engaged to attend a case, invariably
to ask that during the seventh and eighth months the urine should occa-
sionally be sent for examination.
In nephritis from cold and in scarlet fever the symptoms are usually
marked and the diagnosis is rarely in doubt. As already mentioned,
every case in which albumen is present must not be called acute Bright's
disease, not even if tube-casts be present. Thus the common febrile albu-
minuria, although it represents the first link in the chain of events leading
to acute Bright's disease, should not be placed in the same category.
There are occasional cases of acute Bright's disease with anasarca, in
744 DISEASES OF THE KIDNEYS.
which albumen is either absent or pn-esent only as a trace. This is a rare
condition. Tube-casts are usually found, and the absence of albumen is
rarely permanent. The urine may be reduced in amount.
The character of the casts is of use in the diagnosis of the form of
Bright's disease, but scarcely of such extreme value as has been stated.
Thus, the hyaline and granular casts are common to all varieties. The
blood and epithelial casts, particularly those made up of leucocytes, are
most common in the acute cases.
Prognosis. — The outlook varies somewhat with the cause of the
disease. Recoveries in the form following exposure to cold are much
more frequent than after scarlatinal nephritis. In young children the
mortality is high, amounting to at least one third of the cases. Serious
symptoms are low arterial tension, the occurrence of uraemia, and effu-
sion into the serous sacs. The persistence of the dropsy after the first
month, intense pallor, and a large amount of albumen indicate the possi-
bility of the disease becoming chronic. For some months after the dis-
appearance of the dropsy there may be traces of albumen and a few tube-
casts.
In a week or ten days, in a case of scarlatinal nephritis, if the progress
is favorable, the dropsy diminishes, the urine increases, the albumen less-
ens, and by the end of a month the dropsy has disappeared and the urine
is nearly free. In very young children the course may be rapid, and I
have known the urine to be free from albumen in the fourth week. Other
cases are more insidious, and though the dropsy may disappear, the albu-
men persists in the urine, the anaemia is marked, and the condition be-
comes chronic or, after several recurrences of the dropsy, improves and
complete recovery takes place.
Treatment. — The patient should be in bed and there remain until
all traces of the disease have disappeared. As sweating plays such an
important part in the treatment, it is well, if possible, to accustom the
patient to blankets. He should also be clad in thin Canton flannel.
The diet should consist of milk or butter-milk, gruels made of arrow-
root or oat-meal, barley water, and, if necessary, beef tea and chicken
broth. It is better, if possible, to confine the patient to a strictly milk
diet. As convalescence is established, bread and butter, lettuce, water-
cress, grapes, oranges, and other fruits may be given. The return to a
meat diet should be gradual.
The patient should drink freely of alkaline mineral waters, ordinary
water, or lemonade. The fluids keep the kidneys flushed and wash out
the debris from the tubes. A useful drink is a drachm of cream of tartar
in a pint of boiling water, to which may be added the juice of half a lemon
and a little sugar. Taken when cold, this is a pleasant and satisfactory
diluent drink.
No remedies, so far as known, control directly the changes which are
going on in the kidneys. The indications are : (1) To give the excretory
ACUTE BRIGHT'S DISEASE. 745
function of the kidney rest by utilizing the skin and the bowels, in the
hope that the natural processes may be sufficient to effect a cure ; (2) to
meet the symptoms as they arise.
In a case of scarlet fever it may occasionally be possible to avert an
attack, the premonitory symptoms of which are marked increase in the
arterial tension and the presence of blood coloring matter in the urine
(Mahomed). An active saline cathartic may completely relieve this con-
dition.
At the onset, when there is pain in the back or hsematuria, the dry or
wet cups give relief. The latter should not be used in children. Warm
poultices are often grateful. In cases which set in with suppression of
urine, these measures should be adopted, and in addition the hot bath
with subsequent pack, copious diluents, and a free purge. The dropsy is
best treated by hydrotherapy — either the hot bath, the wet pack, or the
hot-air bath. In children the wet pack is usually satisfactory. It is ap-
plied by wringing a blanket out of hot water, wrapping the child in it,
covering this with a dry blanket, and then with a rubber cloth. In this
the child may remain for an hour. It may be repeated daily. In the case
of adults, the hot-air bath or the vapor bath may be conveniently given by
allowing the vapor or air to pass from a funnel beneath the bed-clothes,
which are raised on a low cradle. More efficient, as a rule, is a hot bath of
from fifteen or twenty minutes, after which the patient is wrapped in
blankets. The sweating produced by these measures is usually profuse,
rarely exhausting, and in a majority of cases the dropsy can in this way be
relieved. There are some cases, however, in which the skin does not re-
spond to the baths, and if the symptoms are serious, particularly if uraemia
supervenes, jaborandi or its active principle, pilocarpine, may be used.
The latter may be given hypodermically, in doses of from a sixth to an
eighth of a grain in adults, and from a twentieth to a twelfth of a grain in
children from two to ten years. It is a drug to be used with care. I
abandoned its employment for many years, after having several cases of
serious collapse. Latterly I have resumed its use, often with benefit.
The bowels should be kept open by a morning saline purge ; in children
the fluid magnesia is readily taken ; in adults the sulphate of magnesia may
be given by Hay's method, in concentrated form, in the morning, before
anything is taken into the stomach. In Bright's disease it not infrequently
causes vomiting. The compound powder of jalap, in half -drachm doses,
or, if necessary, elaterium may be used. If the dropsy is not extreme, the
urine not very concentrated, and uraemic symptoms are not present, the
bowels should be kept loose without active purgation. If these measures
fail to reduce the dropsy and it has become extreme, the skin may be
punctured with a lancet or drained by a small silver canula (Southey's
tube), which is inserted beneath it. A fine aspirator needle may be
used, and the fluid allowed to drain through a piece of long, narrow
rubber tubing into a vessel beneath the bed. If the dyspna^a is marked.
74:6 DISEASES OF THE KIDNEYS.
owing to pressure of fluid in the pleurae, aspiration should be performed.
In rare instances the ascites is extreme and may require paracentesis, or a
Southey's tube may be inserted and the fluid gradually withdrawn. If
uraemic convulsions occur, the intensity of the paroxysms may be limited
by the use of chloroform ; to an adult a pilocarpine injection should be at
once given, and from a robust, strong man twenty ounces of blood may be
withdrawn. In children the loins may be dry cupped, the wet pack used,
and a brisk purgative given. Bromide of potassium and chloral sometimes
prove useful.
Vomiting may be relieved by ice and by restricting the amount of food.
Drop doses of creosote, iodine, and carbolic acid may be given. The dilute
hydrocyanic acid with bismuth is often effectual.
The question of the use of diuretics in acute Bright's disease is not yet
settled. The best diuretic, after all, is water, which may be taken freely
with the citrate of potash or the benzoate of soda, salts which are held to
favor the conversion of the urates into less irritating and more easily ex-
creted compounds. Digitalis and strophanthus are useful diuretics, and
may be employed without risk when the arterial tension is low and the
cardiac impulse is not forcible. I have never seen any injurious effects
from their employment after the early symptoms had lessened in intensity.
For the persistent albuminuria, I agree with Roberts and Rosenstein
that we have no remedy of the slightest value. Nothing indicates more
clearly our helplessness in controlling kidney metabolism than inability to
meet this common symptom. Astringents, alkalies, nitroglycerin, and
mercury have been recommended.
For the anaemia always associated with acute Bright's disease iron
should be employed. It should not be given until the acute symptoms
have subsided. In the adult it may be used in the form of the perchloride
in increasing doses, as convalescence proceeds. In children, the syrup of
the iodide of iron or the syrup of the phosphate of iron are better prepara-
tions. The dilatation of the heart is best treated with digitalis, strophan-
thus, and strychnia.
In the convalescence from acute Bright's disease, care should be taken
to guard the patient against cold. The diet should still consist chiefly of
milk and a return to mixed food should be gradual. A change of air is
often beneficial, particularly a residence in a warm, equable climate.
VI. CHRONIC BRIGHT'S DISEASE.
Here, too, in all forms we deal with a diffuse process, involving epi-
thelial, interstitial, and glomerular tissues. Clinically two groups are rec-
ognized— (a) the chronic parenchymatous nephritis, which follows the
acute attack or comes on insidiously, is characterized by marked dropsy,
and post mortem by the la7'f/e while kidney. In the later stages of this
CHRONIC BllIGIlT'S DISEASE. Y47
process the kidney may be smaller — a condition known as the small while
kidney ; {b) chronic interstitial nephritis, in which dropsy is not common
and the cardio-vascular changes are pronounced. Delafield recognizes a
chronic diffuse nephritis with exudation and a chronic productive diffuse
nephritis without exudation, the latter corresponding to the contracted
kidney of authors.
The amyloid kidney is usually spoken of as a variety of Bright's dis-
ease, but in reality it is a degeneration which may accompany any form
of nephritis.
Chronic Parenchy3iatous Nephritis
{Chronic Desquamative and Chronic Tubal Nephritis ; Chronic Diffuse Nephritis with
Exudation).
Etiology. — In many cases the disease follows the acute nephritis of
cold, scarlet fever, or pregnancy. More frequently than is usually stated
the disease has an insidious onset and occurs independently of any acute
attack. The fevers may play an important role in certain of these cases.
Eosenstein, Bartels, and, in this country, I. E. Atkinson have laid special
stress upon malaria as a cause. No instance of the kind has fallen under
my observation during the past seven years, in wdiich time several hun-
dred cases cf malaria have been under my treatment. Beer and alcohol
are believed to lead to this form of nephritis. In chronic suppuration,
syphilis, and tuberculosis the diffuse parenchymatous nephritis is not un-
common, and is usually associated with amyloid disease. Males are rather
more subject to the affection than females. It is met with most commonly
in young adults, and is by no means infrequent in children as a sequence
of scarlatinal nephritis.
Morbid Anatomy. — Several varieties of this form have been recog-
nized. The most common is the large white kidney of Wilks, in which
the organ is enlarged, the capsule is thin, and the surface white with
the stellate veins injected. On section the cortex is swollen and yellowish
white in color, and often presents opaque areas. The pyramids may
be deeply congested. On microscopical examination it is seen that the
epithelium is granular and fatty, and the tubules of the cortex are dis-
tended, and contain tube-casts. Hyaline changes are also present in the
epichelial cells. The glomeruli are large, the capsules thickened, the
capillaries show hyaline changes, and the epithelium of the tuft and of
the capsule is extensively altered. The interstitial tissue is everywhere
increased, though not to an extreme degree.
The second variety of this form results from the gradual increase in
the connective tissue and the subsequent shrinkage, forming what is called
the Hmall white kidney or the pale granular kidney. It is doubtful
whether this is always preceded by the large white kidney. Some observers
hold tliat it may be a primary iudepcndent form. The capsule is thick-
748 DISEASES OF THE KIDNEYS.
ened and the surface is rough and granular. On section the resistance
is greatly increased, the cortex is reduced and presents numerous opaque
white or whitish-yellow foci, consisting of accumulations of fatty epithe-
lium in the convoluted tubules. This combination of contracted kidney
with the areas of marked fatty degeneration has given the name of small
granular, fatty kidney to this form. The interstitial changes are marked,
many of the glomeruli are destroyed, the degeneration of epithelium in the
convoluted tubules is wide-spread, and the arteries are greatly thickened.
Belonging to this chronic tubal nephritis is a variety known as the
chronic liccmorrliagic nepliritis^ in which the organs are enlarged, yellow-
ish white in color, and in the cortex are many brownish-red areas, due to
ha?morrhage into and about the tubes. In other respects the changes are
identical with those in the large white kidney.
Of changes in the other organs the most marked are thickening of the
blood-vessels and hypertrophy of the left heart.
Symptoms. — Following an acute nephritis, the disease may present,
in a modified way, the symptoms of that affection. In many cases it sets
in insidiously, and after an attack of dyspepsia or a period of failing health
and loss of strength the patient becomes pale and puffiness of the eyelids
or swollen feet are noticed in the morning.
The symptoms are as follows : The urine is, as a rule, diminished in
quantity, often scanty. It has a dirty-yellow, sometimes smoky, color
and is turbid from the presence of urates. On standing, a heavy sediment
falls, in which are found numerous tube-casts of various forms and sizes,
hyaline, both large and small, epithelial, granular, and fatty casts. Leuco-
cytes are abundant; red blood-corpuscles are frequently met with, and
epithelium from the kidneys and pelves. The albumen is abundant and
may amount to one half or one third of the urine boiled. It is more
abundant in the urine passed during the day. The specific gravity may
be high in the early stages — from 1*020 to 1-025 — though in the later
stages it is lower. The urea is always reduced in quantity.
Dropsy is a marked and obstinate symptom of this form of Bright's
disease. The face is pale and puffy, and in the morning the eyelids are
cedematous. The anasarca is general, and there may be involvement of
the serous sacs. In these chronic cases associated with large white kidney
there is often a distinctive appearance in the face ; the complexion is pasty,
the pallor marked, and the eyelids are cedematous. The dropsy is pecul-
iarly obstinate. Ursemic symptoms are common, though convulsions are
perhaps less frequent than in the interstitial nephritis.
The tension of the pulse is usually increased ; the vessels ultimately
become stiff and the heart hypcrtrophied, though there are instances of
this form of nephritis in which the heart is not enlarged. The aortic
second sound is accentuated. Retinal changes though less frequent than
in the chronic interstitial nephritis, occur in a considerable number of
cases.
CHRONIC BRIGIIT'S DISEASE. 749
Gastro-intestinal symptoms are common. Vomiting is frequently a
distressing and serious symptom, and diarrhoea may be profuse. Ulcera-
tion of the colon may occur and prove fatal.
It is sometimes impossible to determine, even by the most careful ex-
amination of the urine or by analysis of the symptoms, whether the con-
dition of the kidney is that of the large white or of the small white form.
In cases, however, which have lasted for several years, with the progressive
increase in the renal connective tissue and the cardio-vascular changes,
the clinical picture may approach, in certain respects, that of the con-
tracted kidney. The urine is increased, with low specific gravity. It is
often turbid, may contain traces of blood, the tube-casts are numerous
and of every variety of form and size, and the albumen is abundant.
Dropsy is usually present, though not so extensive as in the early stages.
Th.e prognosis is extremely grave. In a case which has persisted for
more than a year recovery rarely takes place. Death is caused either by
great eif usion with oedema of the lungs, by uraemia, or by secondary inflam-
mation of the serous membranes. Occasionally in children, even when
the disease has persisted for two years, the symptoms disappear and recov-
ery takes place.
Treatment. — Essentially the same treatment should be carried out
as in acute Bright's disease. Milk or butter-milk should constitute the
chief article of food. The dropsy should be treated by hydrotherapy.
Iron preparations should be given freely. The acetate of potash and
digitalis are useful in increasing the flow of urine. Basham's mixture
given in plenty of water will be found beneficial.
Chroxic Interstitial Nephritis.
{Contracted Kidney; Granular Kidney ; Cirrhosis of the Kidney ; Gouty Kidney;
Renal Sclerosis).
Sclerosis of the kidney is met with {a) as an occasional sequence of
the large white kidney, forming the so-called pale granular or secondary
contracted kidney; (h) as an independent primary affection; {c) as a
sequence of arterio-sclerosis.
Etiology. — The primary form is chronic from the outset, and is a
slow, creeping degeneration of the kidney substance — in many respects
only an anticipation of the gradual changes which take place in the organ
in extreme old age. In many cases no satisfactory cause can be assigned.
In others there are hereditary influences, as in the remarkable family
studied by Dickenson, in which a pronounced tendency to chronic Bright's
disease occurred in four generations. Families in which the arteries tend
to degenerate early are more prone to interstitial nephritis. Syphilis is
held by some to be a cause. Alcohol probably plays an important part,
jiarticularly in conjunction with other factors. Dietetic influences are at
work in many cases. Some believe excessive use of meat is injurious, since it
750 DISEASES OP THE KIDNEYS.
increases the materials out of which uric acid is formed. By many a func-
tional disorder of the liver, leading to lithaemia, is regarded as the most
efficient factor. It is quite possible that in persons who habitually eat
and drink too much the work thrown upon this organ is excessive, and
the elaboration of certain materials so defective that in their excretion
from the general circulation they irritate the kidneys.
Actual gout, which in England is a common cause of interstitial ne-
phritis, is not an important factor here. On the other hand, the nutri-
tional disorder known as litha^mia is very common, either with or without
dyspepsia. Lead, as is well known, may produce renal sclerosis, but it
is a minor factor in comparison with other causes. It is doubtful if
climate has any influence. Purdy regards the cold, moist regions of the
Northeastern States as specially favorable to the disease.
Among factors which may account for the prevalence of chronic
Bright's disease in the better classes in this country may be mentioned
the intense worry and strain of business, combined, as they often are,
with habits of hurried and over eating and a lack of proper exercise.
Males are more commonly attacked than females. Under twenty-five
years of age it is a rare disease ; between twenty-five and forty a few well-
marked cases occur ; between forty and sixty it is common.
Morbid Anatomy. — The kidne3^s are usually small, and together
may weigli no more than an ounce and a half. The capsule is thick and
adherent ; the surface of the organ irregular and covered with small nod-
ules, which have given to it the name of granular kidney. In stripping off
the capsule, portions of the kidney substance are removed. Small cysts
are frequently seen on the surface. The color is usually reddish, often a
very dark red. On section the substance is tough and resists cutting ;
the cortex is thin and may measure no more than a couple of millimetres.
The pyramids are less wasted. The small arteries are greatly thickened
and stand out prominently. The fat about the pelvis is greatly increased.
Microscopically there is seen a marked increase in the connective tis-
sue and degeneration and atrophy of the secreting structures, glomerular
and tubal, the former being most predominant and giving the main char-
acters to the lesion. The following are the most important changes :
(a) An increase in the fibrous elements, widely distributed throughout
the organ, but more advanced in the cortex, particularly in the tissue be-
tween the medullary rays. In the pyramids the distribution of new growth
is less patchy and more diffuse. In the early stages of the process there
is a small-celled infiltration between the tubes and around the glomeruli,
and finally this becomes fibrillatcd and is seen encircling the tubules and
Bowman's capsules, around the latter often forming concentric layers.
{b) The changes in the glomeruli are striking, and in advanced cases
a very considerable number of them have undergone complete atrophy and
are represented as densely encapsulated hyaline structures. The atrophy
is partly due to changes in the capillary walls and multiplication of cells
CHRONIC BRIGTIT'S DISEASE. Y51
between the loops, partly to extensive hyaline degeneration, and in part,
no doubt, to the alterations in the afferent vessels. The normal glomeruli
usually show some thickening of the capsule and increase in the cells of
the tufts.
(c) The tubules show changes in the epithelium, which vary a good
deal in different localities. Where the connective-tissue growth is most
advanced they are greatly atrophied and the epithelium may be repre-
sented by small cubical cells. In other instances the epithelium has
entirely disappeared. On the other hand, in the regions represented by
the projecting granules the tubules are usually dilated, and the epithelium
shows hyaline, fatty, and granular changes. Very many of them contain
dark masses of epithelial debris and tube-casts. In the interstitial tissue
and in the tubules there may be pigmentary changes due to lusmorrhage.
The dilatation of the tubules may reach an extreme grade, forming definite
cysts.
(d) The arteries show an advanced sclerosis. The intima is greatly
thickened and there are changes in the adventitia and in the media, con-
sisting in increase in the thickness due to proliferation of the connective
tissue, in the latter coat at the expense of the muscular elements.
The view most generally entertained at present is that the essential
lesion is in the secreting tissues of the tubules and the glomeruli, and that
the connective-tissue overgrowth is secondary to this. Greenfield holds
that the primary change is in most instances in the glomeruli, to which
both the degeneration in the epithelium of the convoluted tubules and the
increase in the intertubular connective tissue are secondary.
Associated with contracted kidney are general arterio-sclerosis and
hypertrophy of the heart. The changes in the arteries have already been
described in the section on arterio-sclerosis. The hypertrophy of the heart
is almost constant. I do not remember ever to have seen a well-marked
instance of contracted kidney without some hypertrophy of the left ven-
tricle, and the enlargement may reach an extreme grade. The varia-
tions depend, no doubt, in part upon the extent of the diffuse arterial
degeneration, and there are instances in which the term cor hovinum may
be applied to the enlarged organ. In such cases the hypertrophy is not
confined to the left ventricle, but involves the entire heart. The explana-
tion of this hypertrophy has been much discussed. It was at first held to
be due to the increased work thrown upon the organ in driving the impure
blood through the capillary system. Basing his opinion upon the sup-
posed muscular increase in the smaller arteries, Johnson regarded the
hypertrophy as effort to overcome a sort of stop-cock action of these ves-
sels, which, un^er the influence of the irritating ingredient in the blood,
contracted and increased greatly the peripheral resistance. Traube be-
lieved that the obliteration of a large number of capillary territories in
the kidney materially raised the arterial pressure, and in this way led to
the hypertrophy of tlie heart ; an additional factor, he thought, was the
752 DISEASES OP THE KIDNEYS.
diminished excretion of water, which also heightened the pressure within
the blood-vessels.
In OUT present knowledge the most satisfactory explanation is that
given by Cohnheim, which is thus clearly and succinctly put by Fagge :
" He gives reasons for thinking that the activity of the circulation through
the kidneys at any moment — in other words, the state of the smaller renal
arteries as regards contraction or dilatation — depends not (as in the case
of the tissues generally) upon the need of those organs for blood, but
solely upon the amount of material for the urinary secretion that the cir-
culatory fluid happens then to contain. This suggestion has bearings
. . . upon the development of hypertrophy in one kidney when the other
has been entirely destroyed. But another consequence deducible from it is
that when parts of both kidneys have undergone atrophy, the blood-flow
to the parts that remain must, cceteris paribus^ be as great as it would
have been to the whole of the organs if they had been intact. But in
order that such a quantity of blood should pass through the restricted
capillary area now open to it, an excessive pressure must obviously be
necessary. This can be brought to bear only by the exertion of more than
the normal degree of force on the part of the left ventricle, combined with
the maintenance of a corresponding resistance in all other districts of the
arterial system. And so one can account at once for the high arterial
pressure and for the cardio-vascular changes that are secondary to it."
Symptoms. — Perhaps a majority of the cases are latent, and are not
recognized until, the occurrence of one of the serious or fatal complica-
tions. Even an advanced grade of contracted kidney may be compatible
with great mental and bodily activity. There may have been no symptoms
whatever to suggest to the patient the existence of a serious malady. In
other cases the general health is disturbed. The patient complains of
lassitude, is sleepless, has to get up at night to micturate ; the digestion is
disordered, the tongue is furred ; there are complaints of headache, failing
vision, and breathlessness on exertion.
So complex and varied is the clinical picture of chronic Bright's dis-
ease that it will be best to consider the symptoms under the various
systems.
Urinary System. — The amount of urine is usually increased, and from
two to four litres may be passed. Frequently the patient has to get up
two or three times during the night to empty the bladder, and there is in-
creased thirst. It is for these symptoms occasionally that relief is sought.
It is to be remembered, however, that frequent micturition at night may
be associated with irritability of the prostate and, in certain cases, with
hyperacidity of the urine. The secretion is clear, the pucus cloud is
well marked, but there is no definite sediment. The color is a light yellow,
and the specific gravity ranges from 1*005 to 1-012. Traces of albumen
are found, but may be absent at times, particularly in the early morning
urine. It is often simply a slight cloudiness, and may be apparent only
CHRONIC BRIGIIT'S DISEASE. 753
with the more delicate tests. The sediment is scanty, and in it a few hya-
line or granular casts are found. The quantity of the solid constituents
of the urine is, as a rule, diminished, though in some instances the urea
may be excreted in full amount. In attacks of dyspepsia or bronchitis,
or in the later stages when the heart fails, the quantity of albumen may
be greatly increased and the urine diminished. Occasionally blood occurs
in the urine, and there may even be haematuria (S. West).
Circulatory System. — The pulse is hard, the tension increased, and
the vessel wall, as a rule, thickened. As already mentioned, a distinction
must be made between increased tension and thickening of the arterial
wall. The tension may be plus in a normal vessel, but in chronic Bright's
disease it is more common to find the tension is increased and the artery
stiff.
A pulse of increased tension has the following characters : (a) It is
hard and incompressible, requiring a good deal of force to overcome it ; {h)
it may be impossible to obliterate the pulse wave by any pressure on the
vessel ; {c) it is persistent, and in the intervals between the beats the ves-
sel feels full and can be rolled beneath the finger. These characters may
be present in a vessel the walls of which are little, if at all, increased in
thickness. To estimate the latter the pulse wave should be obliterated in
the radial, and the vessel wall felt beyond it. In a perfectly normal ves-
sel the arterial coats, under these circumstances, cannot be differentiated
from the surrounding tissue ; whereas, if thickened, the vessel can be
rolled beneath the finger. Persistent high tension is one of the earliest
and most important symptoms of interstitial nephritis. The cardiac feat-
ures are equally important, though often less obvious. Hypertrophy of
the left ventricle occurs to overcome the resistance offered in the arteries.
The enlargement of the heart ultimately becomes more general. The
apex is displaced downward and to the left ; the impulse is forcible and
may be heaving. In elderly persons with emphysema, the displacement
of the apex may not be evident. The first sound at the apex may be
duplicated ; more commonly the second sound at the aortic cartilage is
accentuated, a very characteristic sign of increased tension. The sound
in extreme cases may have a bell-like quality. In many cases a systolic
murmur develops at the apex, probably as a result of relative insufficiency.
It may be loud and transmitted to the axilla. Finally the hypertrophy
fails, the heart becomes dilated, gallop rhythm is present, and the general
condition is that of a chronic heart-lesion.
Respiratory System. — Sudden oedema of the glottis may occur. Ef-
fusion into the pleurae or sudden oedema of the lungs may prove fatal.
Acute x>leurisy and pneumonia are not uncommon. Bronchitis is a fre-
quent accompaniment, particularly in the winter. Sudden attacks of
oppressed breathing, particularly at night, are not infrequent. This is
often a uraimic symptom, but is sometimes cardiac. The patient may sit
up in bed and gasp for breath, as in true asthma. Cheyne-Stokes breath-
754 DISEASES OF THE KIDNEYS.
ing may be present, most commonly toward the close, but the patient
may be Avalking about and even attending to his occupation.
Digestive System. — Dyspepsia and loss of appetite are common. Severe
and uncontrollable vomiting may be the first symptom. This is usually
regarded as a manifestation of uroemia, but it may be present without any
other indications, and I have known it to prove fatal without any suspi-
cion that chronic Bright's disease was present. Severe and even fatal
diarrhoea may develop. The tongue may be coated and the breath heavy
and urinous.
Xervous System. — Various cerebral manifestations have already been
mentioned under uroemia, and they are among the most important of the
features of chronic Bright's disease. Cerebral apoplexy is closely related to
interstitial nephritis. The haemorrhage may take place into the meninges
or the cerebrum. It is usually associated with marked changes in the
vessels. Neuralgias, in various regions, are not uncommon.
Special Senses. — Troubles in vision may be the first symptom of the
disease. It is remarkable in how many cases of interstitial nephritis the
condition is diagnosed first by the ophthalmic surgeon. The flame-shaped
haemorrhages are the most common. Less frequent is diffuse retinitis or
papillitis. Sudden blindness may supervene without retinal changes —
uraemic amaurosis. Auditory troubles are by no means infrequent in chronic
Bright's disease. Ringing in the ears, with dizziness, is not uncommon.
Various forms of deafness may occur.
Skin. — (Edema is not common in interstitial nephritis. Slight puffi-
ness of the ankles may be present, but in a majority of the cases dropsy
does not supervene. When extensive, it is almost always the result of
gradual failure of the hypertrophied heart. The skin is often dry and
pale, and sweats are not common. In some instances the sweat may de-
posit a white frost of urea on the surface of the skin. Eczema is a com-
mon accompaniment of chronic interstitial nephritis. Tingling of the
fingers or numbness and pallor — the dead fingers — are not, as some sup-
pose, in any way peculiar to Bright's disease. Intolerable itching of the
skin may be present, and cramps in the muscles are by no means rare.
Haemorrhages are not infrequent ; thus, epistaxis may occur and prove
serious. Purpura may develop. Broncho-pulmonary haemorrhages are
said, by some French writers, to be common, but no instance of it has
come under my observation. Ascites is rare except in association with
cirrhosis of the liver.
Diagnosis. — The autopsy often discloses the true nature of the dis-
ease, one of tlie many intercurrent affections of which may have proved
fatal. The early stages of interstitial nephritis are not recognizable. In
a patient with increased pulse tension (particularly if the vessel wall
is sclerotic), with the apex beat of the heart dislocated to the left, the
second aortic sound ringing and accentuated, the urine abundant and of
low specific gravity, with a trace of albumen and an occasional hyaline or
CHRONIC BRIGIIT'S DISEASE. 755
granular cast, the diagnosis of interstitial nephritis may be safely made.
Of all the indications, that offered by the pulse is the most important.
Persistent high tension with thickening of the arterial wall in a man un-
der fifty means that serious mischief has already taken place, that cardio-
vascular changes are certainly, and renal most probably, present. It is
important in the diagnosis of this condition not to rest content with a
single examination of the urine. Both the evening and the morning secre-
tion should be studied. The sediment should be collected in a conical
glass, and in looking for tube-casts a large surface should be examined
with a tolerably low power and little light. The arterio-sclerotic kidney
may exist for a long time without the occurrence of albumen, or the albu-
men may be in very small quantities. In many cases it is impossible to
differentiate the primary interstitial nephritis from an arterio-sclerotic
kidney, nor clinically is it of any special value so to do. In persons
under forty, with very high tension, great thickening of the superficial ar-
teries, and marked hypertrophy of the heart, the renal are more likely to
be secondary to the arterial changes.
Prognosis. — Chronic Bright's disease is an incurable affection, and
the anatomical conditions on which it depends are quite as much beyond
the reach of medicines as wrinkled skin or gray hair. Interstitial
nephritis, however, is compatible with the enjoyment of life for many
years, and it is now universally recognized that increased tension, thick-
ening of the arterial walls, and polyuria with a small quantity of albumen,
neither doom a man to death within a short time nor necessarily interfere
with the pursuits of an active life so long as proper care be taken. I
know patients who have had high tension and a little albumen in the
urine with hyaline casts for ten, twelve, and, in one instance, fifteen years.
Serious indications are the development of uraemic symptoms, dilatation of
the heart, the onset of serous effusions, the development of Cheyne-
Stokes breathing, persistent vomiting, and diarrhoea.
Treatment. — Patients without local indications or in whom the con-
dition has been accidentally discovered should so regulate their lives as to
throw the least possible strain upon heart, arteries, and kidneys. A quiet
life without mental worry, with gentle but not excessive exercise, and resi-
dence in an equable climate, should be recommended. In addition they
should be toh]/ to keep the bowels regular, the skin active by a daily tepid
bath with friction, and the urinary secretion free by drinking daily a
definite amount of either distilled water or some pleasant mineral water.
Alcohol should be strictly prohibited. Tea and coffee are allowable.
The diet should be light and nourishing, and the patient should be
warned not to eat excessively, and not to take meat more than once a day.
Care in food and drink is probably the most important element in the
treatment of these early cases.
A patient in good circumstances may be urged to go away diiring the
winter months, or, if necessary, to move altogether to a warm equable cli-
48
756 DISEASES OF THE KIDNEYS.
mate, like that of southern California. There is no doubt of the value in
these cases of removal from the changeable, irregular weather which pre-
vails in the temperate regions from November until April.
At this period medicines are not required unless for certain special
symptoms. Patients derive much benefit from an annual visit to certain
mineral springs, such as Poland, Bedford, Saratoga, in this country, and
Vichy and others in Europe. Mineral waters have no curative influence
upon chronic B right's disease ; they simply help the interstitial circulation
and keep the drains flushed. In this early stage, when the patient's con-
dition is good, the tension not high, and the quantity of albumen small,
medicines are not indicated, since no remedies are known to have the slight-
est influence upon the progress of the disease. Sooner or later symptoms
arise which demand treatment. Of these the following are the most im-
portant :
(a) Greatly Bicr eased Arterial Tension. — It is to be remembered that
a certain increase of tension is not only necessary but unavoidable in
chronic Bright's disease, and probably the most serious danger is too
great lowering of the blood tension. The happy medium must be sought
between such heightened tension as throws a serious strain upon the heart
and risks rupture of the vessels and the low tension which, under these
circumstances, is specially liable to be associated with serous effusions. In
cases with persistent high tension the diet should be light, an occasional
saline purge should be given, and sweating promoted by means of hot air
or the hot bath. If these measures do not suffice, nitroglycerin may be
tried, beginning with one minim of the one per cent, solution three
times a day, and gradually increasing the dose if necessary. Patients
vary so much in susceptibility to this drug that in each case it must be tested,
the limit of dosage being that at which the patient experiences the physio-
logical effect. As much as ten minims of the one per cent, solution may
be given three times a day. In many cases I have given it in much larger
doses for weeks at a time. I have never seen any ill efi'ects from it. If
the dose is excessive the patients complain at once of flushing or headache.
Its use may be kept up for six or seven weeks, then stopped for a week
and resumed. Its value is seen not only in the reduction of the tension,
but also in the striking manner in which it relieves the headache, dizzi-
ness, and dyspnoea.
{b) More or less anaemia is present in advanced cases, which is best
met by the use of iron. AVeir Mitchell, who has had a unique experience
in certain forms of chronic Bright's disease, gives the tincture of the per-
chloride of iron in large doses— from half a drachm to a drachm three
times a day. He thinks that it not only benefits the anaemia, but that it
also is an important means of reducing the arterial tension.
(c) Many patients with Bright's disease present themselves for treat-
ment with signs of cardiac dilatatioi\ ; there is a gallop rhythm or the heart
sounds have a fcetal character, the breath is short, the urine scanty and
AMYLOID DISEASE. 757
highly albuminous, and there are signs of local dropsy. In these oases
the treatment must be directed to the heart. A morning dose of salts or
calomel may be given, and digitalis in ten-minim doses, three or four
times a day. Strychnia may be used with benefit in this condition. In
some instances other cardiac tonics may be necessary, but as a rule the
digitalis acts promptly and well.
[d) Urcemic Symptoms. — Even before marked manifestations are present
there may be extreme restlessness, mental wandering, a heavy, foul breath,
and a coated tongue. Headache is not often complained of, though intense
frontal headache may be an early symptom of uraemia. In this condition,
too, the patient may complain of palpitation, feelings of numbness, and
sometimes nocturnal cramps. For these symptoms the saline purgatives
should be ordered, and hot baths, so as to induce copious sweating. Nitro-
glycerin also may be freely used to reduce the tension. For the ursemic
convulsions, if severe, inhalations of chloroform may be used. If the pa-
tient is robust and full-blooded, from twelve to twenty ounces of blood
should be removed. The patient should be freely sweated, and if the
convulsions tend to recur chloral may be given, either by the mouth or
per rectum, or, better still, morphia. Uraemic coma must be treated by
active purgation, and sweating should be promoted by the use of pilocar-
pine or the hot bath. For the restlessness and delirium morphia is indis-
pensable. Since its recommendation in ursemic states some years ago,
by Stephen MacKenzie, I have used this remedy extensively and can
speak of its great value in these cases. I have never seen ill effects or any
tendency to coma follow.
VII. AMYLOID DISEASE.
Amyloid (lardaceous or waxy) degeneration of the kidneys is simply an
event in the process of chronic Bright's disease, most commonly in the
chronic parenchymatous nephritis following fevers or of cachectic states.
It has no claim to be regarded as one of the varieties of Bright's disease.
The affection of the kidneys is generally a part of a wide-spread amyloid
degeneration occurring in prolonged suppuration, as in disease of the bone,
in syphilis, tuberculosis, and less commonly in association with leuktemia,
lead poisoning, and gout.
Anatomically the amyloid kidney is large and pale, the surface smooth,
and the venae stellatae well marked. On section the cortex is large and
may show a peculiar glistening, infiltrated appearance, and the glomeruli
are very distinct. The pyramids, in striking contrast to the cortex, are of
a deep red color. A section soaked in dilute tincture of iodine shows spots
of a walnut or mahogany brown color. The Malpighian tufts and the
straight vessels may be most affected. In lardaceous disease of the kid-
neys the organs are not always enlarged. They may be normal in size or
758 DISEASES OF THE KIDNEYS.
small, pale, and granular. The amyloid change is first seen in the Mal-
pighian tufts, and then involves the afferent and efferent vessels and the
straight vessels. It may be confined entirely to them. In later stages of
the disease the tubules are affected, chiefly the membrane, rarely, if ever,
the cells themselves. In addition, the kidneys always show signs of diffuse
nephritis. The Bowman's capsules are thickened, there may be glomeruli-
tis, and the tubal epithelium is swollen, granular, and fatty.
Symptoms. — The renal features alone may not indicate the presence
of this degeneration. Usually the associated condition gives a hint of the
nature of the process. The urine, as a rule, shows important changes ;
the quantity is increased, and it is pale, clear, and of low specific gravity.
The albumen is usually abundant, but it may be scanty, and in rare in-
stances absent. Possibly the variations in the situation of the amyloid
changes may account for this, since albumen is less likely to be present
when the change is confined to the vasae rectae. In addition to ordinary
albumen, globulin may be present. The tube-casts are variable, usually
hyaline, often fatty or finely granular. Occasionally the amyloid reaction
can be detected in the hyaline casts. Dropsy is present in many instances,
particularly when there is much anaemia or profound cachexia. It is not?
however, an invariable symptom, and there are cases in which it does not
develop.
Increased arterial tension and cardiac hypertrophy are not usually
present, except in those cases in which amyloid degeneration occurs in the
secondary contracted kidney ; under which circumstances there may be urae-
mia and retinal changes, which, as a rule, are not met with in other forms.
Diagnosis. — By the condition of the urine alone it is not possible to
recognize amyloid changes in the kidney. Usually, however, there is no
difficulty, since the Bright's disease comes on in association with s}^hilis,
prolonged suppuration, disease of the bone, or tuberculosis, and there is
evidence of enlargement of the liver and spleen. A suspicious circum-
stance is the existence of polyuria with a large amount of albumen in the
urine, or when, in these constitutional affections, a large quantity of clear,
pale urine is passed, even without the presence of albumen.
The prognosis depends rather on the condition with which the nephri-
tis is associated. As a rule it is grave.
The treatment of the condition is that of chronic Bright's disease.
VIII. PYELITIS
{Consecutive Nephritis ; Pyelonephritis ; Pyonephrosis).
Definition. — Inflammation of the pelvis of the kidney and the con-
ditions which result from it.
Etiology. — Pyelitis is induced by many causes, among which the
following are the most important : {a) The irritation of calculi — a very
PYELITIS. 759
frequent cause, (b) Tubercle, (c) The infectious pyelitis which develops
in typhoid fever, pneumonia, scarlet fever, diphtheria, small-pox, and other
fevers. Here an acute inflammation of the pelvis of the kidney may occur,
sometimes haemorrhagic in character, more frequently diphtheritic, (d)
The presence of decomposing urine, following pressure upon the ureter by
tumors or bladder-disease. By far the most' frequent form of pyelitis is
that which is consecutive to cystitis, from whatever cause. In these cases
the inflammation may not be confined to the pelvis, but pass to the
kidney, inducing pyelonephritis, (e) Occasional causes are cancer, hyda-
tids, the ova of certain parasites, and, according to some, the irritation of
the saccharine urine of diabetes, and the irritation of turpentine or cubebs.
(/) A primary pyelitis or pyelonephritis has been described as coming on
after cold or overexertion, but such cases are extremely rare.
Morbid Anatomy. — In the early stages of pyelitis the mucous mem-
brane is turbid, somewhat swollen, and may show ecchymoses. The urine
in the pelvis is cloudy, and, on examination, numbers of epithelial cells are
seen. In the form associated with the infectious fevers there is usually a
grayish pseudo-membrane, either limited to an infundibulum or involving
a great part of the pelvis.
In the calculous pyelitis there may be only slight turbidity of the mem-
brane, which has been called by some catarrhal pyelitis. More commonly
the mucosa is roughened, grayish in color, thick, and, on microscopical
examination, the tissues are seen to be infiltrated with leucocytes. Un-
der these circumstances there is almost always more or less dilatation
of the calyces and flattening of the pajjillae. Following this condition
there may be (a) extension of the suppurative process to the kidney it-
self, forming a pyelonephritis; (b) a gradual dilatation of the calyces
with atrophy of the kidney substance, and finally the production of the
condition of pyonephrosis, in which the entire organ is represented by a
sac of pus with or without a thin shell of renal tissue, (c) After the kid-
ney structure has been destroyed by suppuration, and the obstruction at
the orifice of the pelvis persists, the fluid portions may be absorbed, the
pus becomes inspissated, so that the organ is represented by a series of
sacculi containing grayish, putty-like masses, which may become impreg-
nated with lime salts.
Tuberculous pyelitis, as already described, usually starts upon the apices
of the pyramids, and may at first be limited in extent. Ultimately the
condition produced may be similar to that of calculous pyelitis. Pyone-
phrosis is quite as frequent a sequence, while the final transformation of
the pus into a putty-like material impregnated with salts, forming the
so-called scrofulous kidney, is even commoner.
The pyelitis consecutive to cystitis is usually bilateral, and the kidney
is apt to be involved, forming the so-called surgical kidfiey — acute sup-
purative nephritis. There are lines of suppuration extending along the
pyramids, or small abscesses in the cortex, often just beneath the capsule;
760 DISEASES OF THE KIDNEYS.
or there may be wedge-shaped abscesses. The pus organisms either pass
up the tubules or, as Steven has shown, pass by the lymphatics.
Symptoms. — The forms associated with the fevers rarely cause any
sym})toms, even when the process is extensive. In mild grades there is
pain in the back or there may be tenderness on deep pressure on the af-
fected side. The urine is tufbid, contains a few mucous and pus cells, and
occasionally blood-corpuscles. The urine is acid, and there may be a trace
of albumen.
Before the condition of pyuria is established there may be attacks of
pain on the affected side (not amounting to the severe agony of renal colic),
rigors, high fever, and sweats. Under these circumstances the urine,
which may have been clear, becomes turbid or smoky from the presence of
blood, and may contain large numbers of mucus cells and transitional epi-
thelium. These cases are not common, but I have twice had opportunity
of studying such attacks for a prolonged period. In one patient the oc-
currence of the rigor and fever could sometimes be predicted from the
change in the condition of the urine. Such cases occur, I believe, in as-
sociation with calculi in the pelvis.
The statement is not infrequently made that the epithelium in the
urine in pyelitis is distinctive and characteristic. This is erroneous,
as may be readily demonstrated by comparing scrapings of the mucosa of
the pelvis and of the bladder. In both the epithelium belongs to what is
called the transitional variety, and in both regions the same conical, fusi-
form and irregular cells with long tails are found.
When the pyelitis, whether calculous or tuberculous, has become
chronic and suppurative, the symptoms are :
(1) Pyuria. — The pus is in variable amount, and may be intermittent.
Thus, as is often the case when only one kidney is involved, the ureter
may be temporarily blocked, normal urine is passed for a time, and then
there is a sudden outflow of the pent-up pus and the urine becomes puru-
lent. Coincident with this retention, a tumor mass may be felt on the
side affected. The pus has the ordinary characters, but the transitional
epithelium is not so abundant at this stage and comes from the bladder or
from the pelvis of the healthy side. Occasionally in rapidly advancing
pyelonephritis portions of the kidney tissue, particularly of the apices of
the pyramids, may slough away and appear in the urine ; or, as in a re-
markable specimen shown to me by Tyson, solid cheesy moulds of the
calyces are passed. Casts from the kidney tubules are sometimes present.
The reaction of the urine. is at first acid, and may remain so even when
the pus is passed in large quantities. If it remains any time in the blad-
der or if cystitis exists it becomes ammoniacal. Micturition may be very
frequent and irritability of the bladder may be present.
(2) Intermittent fever associated with rigors is usually present in cases
of suppurative pyelitis. The chills may recur at regular intervals, and
the cases are often mistaken for malaria. Owen-Rees called attention to
PYELITIS. 761
the frequent occurrence of these rigors, which form a characteristic
feature of both calculous and tuberculous pyelitis. Ultimately the fever
assumes a hectic type and tlie rigors may cease.
(3) The general condition of the patient usually indicates prolonged
suppuration. There is more or less wasting with anaimia and a progressive
failure of health. Secondary abscesses may develop and the clinical pict-
ure becomes that of pyaemia. In some instances, particuhirly of tubercu-
lous pyelitis, the clinical course may resemble that of typhoid fever. There
are instances of pyuria recurring, at intervals, for many years without
impairment of the bodily vigor.
(4) Physical examination in chronic pyelitis usually reveals tender-
ness on the affected side or a definite swelling, which may vary much in
size and ultimately attain large dimensions if the kidney becomes enor-
mously distended, as in pyonephrosis.
(5) Occasionally nervous symptoms, which may be associated with
dyspnoea, supervene, or the termination may be by coma, not unlike that
of diabetes. These have been attributed to the absorption of the decom-
posing materials in the urine, and has been called ammoni^mia. A form
of paraplegia has been described in connection with some cases of abscess
of the kidney, but whether due to a myelitis or to a peripheral neuritis
has not yet been determined.
In suppurative nephritis or surgical kidney following cystitis, the pa-
tient complains of pain in the back, the fever becomes high, irregular, and
associated with chills, and in acute cases a typhoid state develops in which
death occurs.
Diagnosis. — Between the tuberculous and the calculous forms of
pyelitis it may be difficult or impossible to distinguish, except by the de-
tection of tubercle bacilli in the pus. This has been done on several occa-
sions, but many slides must be examined, for the bacilli are usually scanty.
From perinephric abscess pyonephrosis is distinguished by the more
definite character of the tumor, the absence of oedematous swelling in
the lumbar region, and, most important of all, the history of the case.
The urine, too, in perinepliric abscess may be free from pus. There
are cases, however, in which it is difficult indeed to make a satisfactory
diagnosis. A patient whom I saw with Fussell had had cystitis through
her pregnancy, subsequently pus in the urine for several months, and then
a large fluctuating abscess developed in the right lumbar region. It did
not seem possible, either before or during the operation, to determine
whether the case was a simple pyonephrosis or whether there had been a
perinephric abscess caused by the pyelitis.
Suppurative pyelitis and cystitis are frequently confounded. I have
known three instances of the former in which perineal section was
performed on the supposition of the existence of an intractable cystitis.
The two conditions may, of course, coexist and prove puzzling, but the
history, the acid character of the pus in many instances, the less frequent
762 DISEASES OF THE KIDNEYS.
occurrence of ammoniacal decomposition, the local signs in one lumbar
region, and tlie absence of pain in the bladder should be sufficient to dif-
ferentiate the affections. In women, by catheterization of the ureters, it
may be definitely determined whether the pus comes from the kidneys or
from the bhidder.
Prognosis. — Cases coming on during the fevers usually recover.
Tuberculous pyelitis may terminate favorably by inspissation of the pus
and conversion into a putty -like substance with deposition of lime
salts. AVhen pyonephrosis develops the dangers are increased. Perfora-
tion may occur, the patient may be worn out by the hectic fever, or amy-
loid disease may develop.
Treatment. — In mild cases fluids should be taken freely, particularly
the alkaline mineral waters, to which the citrate of potash may be added.
The treatment of the calculous form will be considered later. Practi-
cally there are no remedies which have much influence upon the pyuria.
Astringents in no way control the discharge, nor have I seen the slightest
benefit from buchu, copaiba, sandal-wood oil, or uva ursi. Tonics should
be given, a nourishing diet, and milk and butter-milk may be taken freely.
When the tumor has formed or even before it is perceptible, if the symp-
toms are serious and severe, the kidney should be explored, and, if neces-
sary, nephrotomy should be performed.
IX. HYDRONEPHROSIS.
Definition. — Dilatation of the pelvis and calyces of the kidney with
atrophy of its substance, caused by the accumulation of non-purulent
fluids the result of obstruction.
Etiology. — The condition may be congenital, owing to some ab-
normality in the ureter or urethra. The tumor produced may be large
enough to retard labor. Sometimes it is associated with other malforma-
tions. There is a condition of moderate dilatation, apparently congenital,
which is not connected with any obstruction in the ducts. A case of the
kind was shown at the Philadelphia Pathological Society by Daland.
In some instances there has been contraction or twisting of the ureter,
or it has been inserted into the kidney at an acute angle or at a high level.
In adult life the condition may be due to lodgement of a calculus, or to
a cicatricial stricture following ulcer.
New growths, such as tubercle or cancer, occasionally induce hydro-
nephrosis, ^lore commonly, pressure upon the ureter from without, par-
ticularly tumors of the ovaries and uterus. Occasionally cicatricial bands
compress tlie ureter. Obstruction within the bladder may result from
cancer, from hypertrophy of the prostate with cystitis, and in the urethra
from stricture. It is stated that slight grades of hydronephrosis have
been found in patients with excessive polyuria.
nYDRONEPIIROSIS. 763
In whatever way produced, when the ureter is blocked the secretion ac-
cumulates in the pelvis and infundibula. Sometimes acute inflammation
follows, but more commonly the slow, gradual pressure causes atrophy of
the papillae with gradual distention and wasting of the organ. In acquired
cases from pressure, even when dilatation is extreme, there may usually be
seen a thin layer of renal structure. In the most extreme stages the kid-
ney is represented by a large cyst, which may perhaps show on its inner
surface imperfect septa. The fluid is thin and yellowish in color, and
contains traces of urinary salts, urea, uric acid, and sometimes albumen.
The secretion may be turbid from admixture with small quantities of pus.
Total occlusion does not always lead to a hydronephrosis, but may be
followed by atrophy of the kidney. It appears that when the obstruction
is intermittent or not complete the greatest dilatation is apt to follow.
The sac may be enormous, and cause an abdominal tumor of the largest
size. The condition has even been mistaken for ascites. Enlargement of
the other kidney may compensate for the defect. Hypertrophy of the left
side of the heart usually follows.
Symptoms. — When small, it may not be noticed. The congenital
cases when bilateral usually prove fatal within a few days ; when unilateral,
the tumor may not be noticed for some time. It increases progressively
and has all the characters of a tumor in the renal region. In adult life
many of the cases, due to pressure by tumors, as in cancer of the uterus
and enlargement of the prostate, etc., give rise to no symptoms.
There are remarkable instances of intermitteyit hydronephrosis in
which the tumor suddenly disappears with the discharge of a large quan-
tity of clear fluid. The sac gradually refills, and the process may be
repeated for years. In these cases the obstruction is unilateral ; a cicatri-
cial stricture exists, or a valve is present in the ureter, or the ureter enters
the upper part of the pelvis.
The examination of the abdomen shows, in unilateral hydronephrosis,
a tumor occupying the renal region. When of moderate size it is readily
recognized, but when large it may be confounded with ovarian or other
tumors. In young children it may be mistaken for sarcoma of the kidney
or of the retroperitoneal glands, the common causes of abdominal tumor
in early life. Aspiration alone would enable us to differentiate be-
tween hydronephrosis and tumor. The large hydronephrotic sac is fre-
quently mistaken for ovarian tumor. The latter is, as a rule, more mobile,
and rarely fills the deeper portion of the lumbar region so thoroughly.
The ascending colon can often be detected passing over the renal tumor,
and examination per vaginarn, particularly under ether, will give impor-
tant indications as to the condition of the ovaries. In doubtful cases the
sac should be aspirated. The fluid of the renal cyst is clear, or tur})id
from the presence of cell elements, rarely colloid in character ; the specific
gravity is low ; albumen and traces of urea and uric acid are usually present ;
and the epithelial elements in it may be similar to those found in the pel-
76i DISEASES OF THE KIDNEYS.
vis of the kidney. In old sacs, however, the fluid may not be characteristic,
since the urinary salts disappear, but in one case of several years' duration
oxalate of lime and urea were found.
Perhaps the greatest difficulty is offered by the condition of hydro-
nephrosis in a movable kidney. Here, the history of sudden disappear-
ance of the tumor with the passage of a large quantity of clear fluid would
be a point of great importance in the diagnosis. In those rare instances
of an enormous sac filling the entire abdomen, and sometimes mistaken
for ascites, the character of the fluid might be the only point of difference.
The tumor of pyonephrosis may be practically the same in physical char-
acteristics. Fever is usually present, and pus is often found in the urine.
In these cases, when in doubt, exploratory puncture should be made.
The outlook in hydronephrosis depends much upon the cause. A¥hen
single, the condition may never produce serious trouble, and the inter-
mittent cases may persist for years. The latter are the most hopeful,
and Frederick Taylor mentions an instance in which, after the fifth or
sixth subsidence, in the course of two years, a calculus was discharged.
Occasionally the cyst ruptures into the peritonaeum, more rarely through
the diaphragm into the lung. A remarkable case of this kind is at present
under the care of my colleague, Halsted. A man, aged twenty-one, had,
from his second year, attacks of abdominal pain in which a swelling would
appear between the hip and costal margin and subside with the passage
of a large amount of urine. In January, 1888, the sac discharged through
the right lung.* Eeaccumulations have occurred on several occasions
since, and on June 9, 1891, the sac was opened and drained.
The sac may discharge spontaneously through the ureter and the fluid
never reaccumulate. In bilateral hydronephrosis there is a danger that
ursemia may supervene. There are instances, too, in which blocking of
the ureter on the sound side by calculus has been followed by uraemia.
And, lastly, the sac may suppurate, and the condition change to one of
pyonephrosis.
Treatment. — Cases of intermittent hydronephrosis which do not
cause serious symptoms should be let alone. It is stated that, in sacs of
moderate size, the obstruction has been overcome by shampooing. If
practised, it should be done with great care. When the sac reaches a large
size aspiration may be performed and repeated if necessary. Puncture
should be made in the flank, midway between the ilium and the last
rib. If the fluid reaccumulates and the sac becomes large, it may be in-
cised and drained, or, as a last resort, the kidney may be removed.
* Sowers, New York Medical Record, 1888.
NEPHROLITHIASIS. 765
X. NEPHROLITHIASIS {lienal Calculus).
Deiinition. — The formation in the kidney or in its pelvis of con-
cretions, by tlie deposition of certain of the solid constituents of the urine.
Etiology and Pathology. — Iii the kidney substance itself the
separation of the urinary salts produces a condition to which, unfortu-
nately, the term infarct has been applied. Three varieties may be recog-
nized : (1) The uric-acid infarct, usually met with at the apices of the
pyramids in new-born children and during the first weeks of life. It is
readily recognized as a yellowish linear streak in the pyramids and is of
no significance ; (2) the urate of soda infarct, sometimes associated with
urate of ammonia, which forms whitish lines at the apices of the pyramids
and is met with chiefly, but not always, in gouty persons; and (3) the
lime infarcts, forming very opaque white lines in the pyramids, usually in
old people.
In the pelvis and calyces concretions of the following forms occur : {a)
Small gritty particles, renal sanely ranging in size from the individual
grains of the uric-acid sediment to bodies one or two millimetres in diame-
ter. These may be passed in the urine for long periods without producing
any symptoms, since they are too fine to be arrested in their downward
passage.
[b) Larger concretions, ranging in size from a small pea to a bean, and
either solitary or multi2)le in the calyces and pelvis. It is the smaller of
these calculi which, in their passage, produce the attacks of renal colic.
They may be rounded and smooth, or present numerous irregular projec-
tions.
(c) The dendritic form of calculus. The orifice of the ureter may be
blocked by a Y-shaped stone. The pelvis itself may be occupied by the
concretion, which forms a more or less distinct mould. These are the re-
markable coral calculi^ which form in the pelvis complete moulds of in-
fundibula and calyces, the latter even presenting cup-like depressions cor-
responding to the apices of the papillae. Some of these casts in stone of
the renal pelvis are as beautifully moulded as Hyrtl's corrosion prepara-
tions.
Chemically the varieties of calculi are : (1) Uric acid, by far the most
important, which may form the renal sand, the small solitary, or the large
dendritic stones. They are very hard, the surface is smooth, and the color
reddish. The larger stones are usually stratified and very dense. Usually
tlio uric acid and the urates are mixed, but in children stones composed of
urates alone may occur.
(2) Oxahxte of lime, which forms mulberry-shaped calculi, studded with
points and spines. ''I'hey are often very dark in color, intensely hard, and
are a mixture of oxalate of lime and uric acid.
(3) Phosphatic calculi are comj)osed of the phosphate of lime and the
ammonio-magnesium phosphate, sometimes mixed with a small amount of
^QQ DISEASES OF THE KIDNEYS.
carbonate of lime. Tliey are not common, since the pliosphatic salts are
oftener dejoosited about tlie uric acid or the oxalate of lime stones.
(4) Rare forms of calculi are made up of cystine, xanthine, carbonate
of lime, indigo, and urostealith.
The mode of formation of calculi has been much discussed. They may
be produced by an excess of a sparingly soluble abnormal ingredient, such
as cystine or xanthine ; more frequently by the presence of uric acid in a
very acid urine which favors its deposition. Sir William Roberts thus
briefly states the conditions which lead to the formation of the uric-acid
concretions : high acidity, poverty in salines, low pigmentation, and high
percentage of uric acid. The presence of albumen and mucus may deter-
mine, as Ord suggests, the deposition of the uric acid and thus form the
starting point of a stone. Ova of parasites, blood-clot, casts, and shreds of
epithelium may form the nuclei of stones.
Renal calculi are most common in the early and later periods of life.
They are moderately frequent in this country, but there do not appear
to be special districts, corresponding to the " stone counties " in England.
Men are more often affected than women. Sedentary occupations seem
to predispose to stone.
The effects of the calculi are varied. It is by no means uncommon to
find a dozen or more stones of various sizes in the calyces without any
destruction of the mucous membrane or dilatation of the pelvis. A tur-
bid urine fills the pelvis in which there are numerous cells from the
epithelial lining. There are cases of this sort in which, apparently, the
stones may go on forming and are passed for years without seriously im-
pairing the health and without inconvenience, except the attacks of renal
colic. Still more remarkable are the cases of coral-like calculi, which
may occupy the entire pelvis and calyces without causing pyelitis, but
which gradually lead to more or less induration of the kidney. The most
serious effects are when the stone excites a suppurative pyelitis and
pyonephrosis.
Symptoms. — Patients may pass gravel for years without having an
attack of renal colic, and a stone may never lodge in the ureter. In
other instances, the formation of calculi goes on year by year and the pa-
tient has recurring attacks such as have been so graphically described by
Montaigne in his own case. A patient may pass an enormous number of
calculi. Some years ago I was consulted by a commercial traveller, an
extremely vigorous man, who for many years had repeated attacks of
renal colic, and had passed several hundred calculi of various sizes. His
collection filled an ounce bottle. A patient may pass a single calculus,
and never be troubled again. The large coral calculi may excite no
symptoms. In a remarkable specimen of the kind, presented to the
McOill Medical IMuseum by J. A. Macdonald, the patient, a middle-aged
woman, died suddenly with uraemic symptoms. There was no pyelitis,
but the kidneys were sclerotic.
NEPHROLITHIASIS. Y67
Renal colic ensues when a stone enters the ureter. An attack may
set in abruptly without apparent cause, or may follow a strain in lift-
ing. It is characterized by agonizing pain, which starts in the flank of
the affected side, passes down the ureter, and is felt in the testicle and
along the inner side of the thigh. The pain may also radiate through
the abdomen and chest, and be very intense in the back. In severe at-
tacks there are nausea and vomiting and the patient is collapsed. The
perspiration breaks out upon the face and the pulse is feeble and quick.
A chill may precede the outbreak, and the temperature may rise as high
103°. No one has more graphically described an attack of " the stone " than
Montaigne,* who was a sufferer for many years : " Thou art seen to
sweat with joain, to look pale and red, to tremble, to vomit well-nigh to
blood, to suffer strange contortions and convulsions, by starts to let tears
drop from thine eyes, to urine thick, black, and frightful water, or to have it
suppressed by some sharp and craggy stone, that cruelly pricks and tears
thee." The symptoms persist for a variable period. In short attacks
they do not last longer than an hour ; in other instances they continue
for a day or more, with temporary relief. Micturition is frequent, occa-
sionally painful, and the urine, as a rule, is bloody. There are instances
in which a large amount of clear urine is passed, probably from the other
kidney. In rare cases the secretion of urine is completely suppressed,
even when the kidney on the opposite side is normal, and death may
occur from uraemia. This most frequently happens when the second kid-
ney is extensively diseased, or when only a single kidney exists. A number
of cases of this kind have been recorded. The condition has been termed,
by Sir William Roberts, obstructive suppression. It is met with also when
cancer compresses both ureters or involves their orifices in the bladder. The
patient may not appear to be seriously ill at first, and ureemic symptoms
may not develop for a week, when twitching of the muscles, great rest-
lessness, and sometimes drowsiness supervene, but, strange to say, neither
convulsions nor coma. Death takes place usually within twelve days
from the onset of the obstruction.
After the attack of colic has passed there is more or less aching on the
affected side, and the patient can usually tell from which kidney the stone
has come. Examination during the attack is usually negative. Very
rarely the kidney becomes palpable. Tenderness on the affected side is
common. In very thin persons it may be possible, on examination of the
abdomen, to feel the stone in the ureter ; or the patient may complain of
a grating sensation.
When the calculi remain in the kidney they may produce very definite
and characteristic symptoms, of which the following are the most im-
y)ortant :
(1) Pain, usually in the back, which is often no more than a dull sore-
* Essays, Book 111, 13.
708 DISEASES OF THE KIDNEYS.
ness, but which may be severe and come on in paroxysms. It is usually on
the side affected, but may be referred to the opposite kidney, and there are
instances in which the pain has been confined to the sound side. Pains
f»f a similar nature may occur in movable kidneys, and there are several
instances on record in which surgeons have incised the kidney for stone
and found none.
(2) IIcBmaturia. — Although this occurs most frequently when the
stone becomes engaged in the ureter, it may also come on when the stones
are in the pelvis. The bleeding is seldom profuse, as in cancer, but in
some instances may persist for a long time. It is aggravated by exertion
and lessened by rest. Frequently it only gives to the urine a smoky hue.
The urine may be free for days, and then a sudden exertion or a prolonged
ride may cause smokiness, or blood may be passed in considerable quantities.
(3) Pyelitis. — {a) There may be attacks of severe pain in the back,
not amounting to actual colic, which are initiated by a heavy chill followed
by fever, in which the temperature may reach 104° or 105°, followed by
profuse sweating. The urine, which has been clear, may become turbid
and smoky and contain blood and abundant epithelium from the pelvis.
Attacks of this description may recur at intervals for months or even
years, and are generally mistaken for malaria, unless special attention is
paid to the urine and to the existence of the pain in the back. This renal
intermittent fever, due to the presence of calculi, is identical with the
hepatic intermittent fever, due to gall-stones, and in both it is important
to remember that the most intense paroxysms may occur without any evi-
dence of suppuration.
if)) More frequently the symptoms of purulent pyelitis, which have
already been described, are present ; pain in the renal region, recurring
chills, and pus in the urine, with or without indications of pyonephrosis.
(4) Pyuria. — There are instances of stone in the kidney in which pus
occurs continuously or intermittently in the urine for many years. On
many occasions between 1875 and 1884 I examined the urine of a phy-
sician who had passed calculi when a student in 1847, and has had pus in
the urine at intervals ever since. There was no tumor. He had never had
a second attack of colic. In spite of the prolonged suppuration lie has
had remarkable mental and bodily vigor.
Patients with stone in the kidney are often robust, high livers, and
gouty. Attacks of dyspepsia are not uncommon, or they may have severe
headaches.
Diagnosis. — Renal may be mistaken for intestinal colic, particularly
if the distention of the bowels is marked, or for biliary colic. The situa-
tion and direction of the pain, the retraction and tenderness of the testicle,
tlie occurrence of ha^maturia, and the altered character of the urine are
distinctive features. Attention may again be called to the fact that at-
tacks simulating renal colic are associated with movable kidney, or even,
it has been su])p()scd, witliout mobility of the kidney, with the accumu-
NEPHROLITHIASIS. 709
lation of the oxalates or uric acid in tlie pelvis of the kidney. The diag-
nosis between a stone in the kidney and stone in the bladder is not always
easy, though in the latter the pain is particularly abont the neck of the
bladder, and not limited to one side. Important points are the reaction
of the urine, which in stone in the bladder is almost invariably alkaline,
and the abundance of mucus with the pus. It is stated that certain differ-
ences occur in the symj^toms produced by different sorts of calculi. The
large uric-acid calculi less frequently produce severe symptoms. On the
other hand, as the oxalate of lime is a rougher calculus, it is apt to pro-
duce more pain (often of a radiating character) than the lithic-acid form,
and to cause haemorrhage. In both these forms the urine is acid. The
phosphatic calculi are stated to produce the most intense pain, and the
urine is commonly alkaline.
Treatment. — In the attacks of renal colic great relief is experienced
by the hot bath, which is sometimes sufficient to relax the spasm. AVhen
the pain is very intense morphia should be given hypodermically, and in-
halations of chloroform may be necessary until the effects of the anodyne
are manifest. Local applications are sometimes grateful — hot poultices,
or cloths w^rung out of hot water. The patient may drink freely of hot
lemonade, soda water, or barley water. Occasionally change in posture
Avili give great relief, and inversion of the patient is said to be followed by
immediate cessation of the pain.
In the intervals the patient should, as far as possible, live a quiet life,
avoiding sudden exertion of all sorts. The essential feature in the treat-
ment is to keep the urine abundant and, in a majority of the cases, alka-
line. The patient should drink daily a large but definite quantity of
mineral waters * or distilled water, which is just as satisfactory. The
citrate or bicarbonate of potash may be added. The aching pains in the
back are often greatly relieved by this treatment. Many patients find
benefit from a stay at Saratoga, Bedford, Poland, or other mineral springs
in this country, or at Vichy or Ems in Europe.
The diet should be carefully regulated, and similar to that indicated in
the early stages of gout. Sir William Roberts recommends what is known
as the solvent treatment for uric-acid calculi. The citrate of potash is
given in large doses of half a drachm to a drachm every three hours in a tum-
blerful of water. This should be kept up for several months. I have had
no success with this treatment, nor, when one considers the character of the
uric-acid stones usually met with in the kidney, does it seem likely that
any solvent action could be exercised upon them by changes in the urine.
This treatment should be abandoned if the urine becomes ammoniacal.
The surgical treatment of stone in the kidney has advanced rapidly in
the hands of Morris and others. It should be resorted to only when the
* SoirK; of Ihcso, if we judge by the laudatory reports, arc as potent as the waters
of Corsena, rleelaj-ed by Montaigne to be " powerful enough to break stones."
770 DISEASES OF THE KIDNEYS.
attacks of pain are of such frequency as to interfere with the occupation
of the patient, or when pyelitis or pyelonephritis has been excited. Stone
in the kidney is not inconsistent with a long life and with the enjoyment
of a fair measure of health.
XI. TUMORS OF THE KIDNEY.
These are benign and malignant. Of the benign tumors, the most
common are the small nodular fibromata which occur frequently in the
pyramids, the aberrant adrenals which Grawitz has described, and occa-
sionally lii)0)aa^ angioma^ or lympliadenoma. The adenomata may be
congenital. In one of my cases the kidneys were greatly enlarged, con-
tained small cysts, and numerous adenomatous structures throughout
both organs.
Malignant growths — cancer or sarcoma — may be either primary or
secondary. The sarcomata are the most common, either alveolar sarcoma
or the remarkable form containing striped muscular fibres — rhabdo-myoma.
Carcinoma is less frequent, and is of the encephaloid variety.
Primary cancer — meaning by this, malignant disease — is not uncom-
mon, and the statistics given by some writers do not represent the fre-
quency with which it is met wdth, at any rate, in this country. Virchow
gives the ratio to cancer in other parts as one half of one per cent.
The tumors attain a very large size. In one of my cases the left kidney
weighed twelve pounds and almost filled the abdomen. In children they
may reach an enormous size. Morris states that in a boy at the Middlesex
Hospital the tumor weighed thirty-one pounds. They grow rapidly, are
often soft, and hemorrhage frequently takes place into them. In the
sarcomata invasion of the pelvis or of the renal vein is common. The
rhabdo-myomas rarely form very large tumors, and death occurs shortly
after birth. In one of my cases the child lived to the age of three years
and a half. The tumor grew into the renal vein and inferior cava. A
detached fragment passed as an embolus into the pulmonary artery, and a
portion of it blocked the tricuspid orifice.
Symptoms.— The following are the most important: (1) Iloema-
turia. This may be the first indication. The blood is fluid or clotted,
and there may be very characteristic moulds of the pelvis of the kidney and
of the ureter. It would no doubt be possible for such to form in the ha^ma-
turia from calculus, but I have never met with a case of blood-casts of the
pelvis and of the ureter, either alone or together, except in cancer. It is
rare indeed that cancer elements may be recognized as in the urine.
Of the numerous specimens which I have examined, in not one have I
found elements which could be clearly distinguished from the multiform
transitional epithelium constantly present in these cases.
(2) Pain is an uncertain symptom. In several of the largest tumors
TUMORS OF THE KIDNEY. 771
which have come under my observation there has been no discomfort from
beginning to close. When present, it is of a dragging, dull character, sit-
uated in the flank and radiating down the thigh. The passage of the
clots may cause great pain
(3) Progressive emaciation. The loss of flesh is usually marked
and advances rapidly. There may, however, be a very large tumor with-
out emaciation.
Physical Signs. — In almost all instances tumor is present. When
small and on the right side, it may be very movable ; in some instances,
occupying a position in the iliac fossa, it has been mistaken for ovarian
tumor. The large growths fill the flank and gradually extend toward the
middle line, occupying the right or left half of the abdomen. Inspection
may show two or three hemispherical projections corresponding to dis-
tended sections of the organ. In children the abdomen may reach an
enormous size and the veins are prominent and distended. On bimanual
palpation the tumor is felt to occupy the lumbar region and can usually
be lifted slightly from its bed ; in some cases it is very movable, even when
large ; in others it is fixed, firm, and solid. The respiratory movements
have but slight influence upon it. Rapidly growing renal tumors are
soft, and on palpation may give a sense of fluctuation. A point of con-
siderable importance is the fact that the colon crosses the tumor, and can
usually be detected without difficulty.
Diagnosis. — In children very large abdominal tumors are either
renal or retroperitoneal. The retroperitoneal sarcoma (Lobstein's can-
cer) is more central, but may attain as large a size. If the case is seen only
toward the end, a differential diagnosis may be impossible ; but as a rule the
sarcoma is less movable. It is to be remembered that these tumors may
invade the kidney. On the left side an enlarged spleen is readily distin-
guished, as the edge is very distinct and the notch or notches well marked ;
it descends during respiration, and the colon lies behind, not in front of
it. On the right side growths of the liver are occasionally confounded
with renal tumors ; but such instances are rare, and there can usually be
detected a zone of resonance between the upper margin of the renal tumor
and the ribs. Late in the disease, however, this is not possible, for the
renal tumor is in close union with the liver.
A malignant growth in a movable kidney may be very deceptive and
may simulate cancer of the ovary or fibroid of the uterus. The great
mobility upward of the renal growth and the negative result of examina-
tion of the pelvic viscera are the reliable points.
Medicinal treatment is of no avail. When the growth is small and the
patient in good condition removal of the organ may be undertaken, but
the percentage of cases of recovery is very small.
49
772 DISEASES OF THE KIDNEYS.
XII. CYSTIC DISEASE OF THE KIDNEY.
The following varieties of cysts are met with :
(1) The small cysts, already described in connection with the chronic
nephritis, which result from dilatation of obstructed tubules or of Bow-
man's capsules.
(2) Solitary cysts, ranging in size from a marble to an orange, or even
larger, are occasionally found in kidneys which present no other changes.
They never give rise to symptoms, though, in exceptional cases, they may
form tumors of considerable size. They, too, in all probability, result
from obstruction.
(3) The congenital cystic kidneys. In this remarkable condition the
kidneys are represented by a conglomeration of cysts, varying in size from
a pea to a marble. The organs are greatly enlarged, and together may
weigh six or more pounds. In the foetus they may attain a size sufficient
to impede labor. Little or no renal tissue may be noticeable, although in
microscopical sections it is seen that a considerable amount remains in
the interspaces. The cysts contain a clear or turbid fluid, sometimes
reddish brown or even blackish in color, and may be of a colloidal consist-
ence. Albumen, blood crystals, cholesterin, with triple phosphates and
fat drops are found in the contents. Urea and uric acid are rarely pres-
ent. The cysts are lined by a flattened epithelium. It is not yet accu-
rately known how these cysts originate. That it is a defect in develop-
ment rather than a pathological change is suggested by the fact that it is
often in the embryo associated with other anomalies, particularly imper-
forate anus. Both Shattock and Bland Sutton, who have studied the
question carefully, believe that the anomaly of develoj)ment is in the fail-
ure of complete differentiation of the Wolffian bodies, which are, as it were,
mixed with the kidneys and give rise to the cysts.
In a large majority of the cases death occurs, either in utero or shortly
after birth ; but instances are met Avith at all ages up to fifty or sixty, and
I see no reason to suppose that these are not instances of persistence of
the congenital form.
In the adult the tumors may be felt in the lumbar region as large
rounded masses.
The symptoms are those of chronic interstitial nephritis. Many of the
cases have presented no indications whatever until a sudden attack of
uraemia ; others have died of heart-failure. A rare termination in a case
at the University Hospital, Philadelpliia, w^as the rupture of one of the
cysts and the production of a perinephritic abscess. The cardio-vascular
changes induced are similar to those of interstitial nephritis. The left
ventricle is hypcrtrophied and the arterial tension is greatly increased.
The condition is compatible with excellent healtli. The dangers are
those associated with chronic Bright's disease. It is important to re-
member that tlie conglomerate cystic kidney is almost invariably bilat-
PERINEPHRIC ABSCESS. 7Y3
eral. One kidney may bo somewhat larger and more cystic than the
other.
The diagnosis can sometimes be made. Great enlargement of both
organs, with hypertrophy of the left heart and increased arterial tension,
would suggest the condition.
Operative interference is not justifiable. I know an instance in
which one kidney was removed and the patient died within twenty-four
hours.
(4) Occasionally the kidneys and liver present numerous small cysts
scattered through the substance. The spleen also may be involved. The
cysts in the kidney are small, and neither so numerous nor so thickly set
as in the conglomerate form, though in these cases the condition is prob-
ably the result of some congenital defect. There are cases, however, in
which the kidneys are very large. It is more common in the lower ani-
mals than in man. I have seen several instances of it in the hog ; in one
case the liver weighed forty pounds, and was converted into a mass of sim-
ple cysts. The kidneys were less involved. Charles Kennedy * states that
he has found references to twelve cases of combined cystic disease of the
liver and kidneys.
The echinococcus cysts will be spoken of under the section on para-
sites.
XIII. PERINEPHRIC ABSCESS.
Suppuration in the connective tissue about the kidney may follow
(1) blows and injuries ; (2) the extension of inflammation from the pelvis
of the kidney, the kidney itself, or the ureters ; (3) perforation of the
bowel, most commonly the appendix, in some instances the colon ; (4)
extension of suppuration from the spine, as in caries, or from the pleura,
as in empyema ; (5) as a sequel of the fevers, particularly in children.
In the post-mortem examination of a case of perinephric abscess the
kidney is found surrounded by pus, particularly at the posterior part,
though the pus may lie altogether in front, between the kidney and the
peritonaeum. Usually the abscess cavity is large and extensive. The pus
is often offensive and may have a distinctly faecal odor from contact with
the large bowel. It may burrow in various directions and may burst into
the pleura and be discharged through the lungs. A more frequent direc-
tion is down the psoas muscle, when it appears in the groin, or it may
pass along the iliacus fascia and appear at Poupart's ligament. It may
perforate the bowel or rupture into the peritonaeum, and in some instances
i4> has penetrated the bladder or vagina.
Post mortem we occasionally find a condition of chronic perinephritis
in which the fatty capsule of the kidney is extremely firm, with numer-
♦ Laboratory Reports of the Royal College of Physicians, Edinburgh, vol. iii.
774 DISEASES OF THE KIDNEYS.
ous bands of fibrous tissue, and is stripped oil from the proper capsule
with the greatest diflficulty. Such a condition probably produces no symp-
toms.
Symptoms. — There may be intense pain, aggravated by pressure, in
the lumbar region. In other instances, the onset is insidious ; there is no
pain in the renal region, but on the first examination signs of deep-seated
suppuration may be detected. On the affected side there is usually pain,
which may be referred to the neighborhood of the hip-joint or radiate
down the thigh and be associated with retraction of the testis. Sometimes
the pain is referred even to the knee-joint, as in hip-disease. The patient
lies with the thigh flexed, so as to relax the psoas muscle, and in walking
throws, as far as possible, the weight on the opposite leg. According to
Gibney, the patient keeps the spine immobile, assumes a stooping posture
in walking, and has great difficulty in voluntarily adducting the thigh.
There may be pus in the urine if the disease has extended from the
pelvis or the kidney, but in other forms the urine is clear. When pus has
formed there are usually chills with irregular fever and sweats. On ex-
amination, deep-seated induration is felt between the last rib and the crest
of the ilium. Bimanual palpation may reveal a distinct tumor mass.
(Edema or puffiness of the skin is frequently present.
The diagnosis of perinephric abscess is usually easy, and in any case
when doubt exists the aspirator needle should be used. We cannot always
differentiate the primary forms from those due to perforation of the kid-
ney or of the bowel. This, however, makes but little difference, for the
treatment is identical. It is usually possible by the history and examina-
tion to exclude disease of the vertebra. In children the condition is often
mistaken for disease of the hip- joint, but the pain is higher, and there is
an entire absence of fulness and tenderness over the hip-joint itself.
From whatever cause produced, the indications for treatment are iden-
tical— early, free, and permanent drainage.
SECTION VIII.
DISEASES OF THE NEEYOUS SYSTEM.
I. DISEASES OF THE NERVES.
I . NEURITIS {Inflammation of the Nerve Fibres).
Neuritis may be localized in a single nerve, or general^ involving a
large number of nerves, in which case it is usually known as ^nultiple
neuritis or polyneuritis.
Etiology. — Localized neuritis arises from {a) cold, which is a very
frequent cause, as, for example, in the facial nerve. This is sometimes
known as rheumatic neuritis, {b) Traumatism — wounds, blows, direct
pressure on the nerves, the tearing and stretching which follow a disloca-
tion or a fracture, and the hypodermic injection of ether. Under this
section come also the professional palsies, due to pressure in the exercise
of certain occupations, (c) Extension of inflammation from neighboring
parts, as in a neuritis of the facial nerve due to caries in the temporal bone,
or in that met with in syphilitic disease of the bones, disease of the joints^
and occasionally in tumors.
Multiple neuritis has a very complex etiology, the causes of which
may be classified as follows : {a) The poisons of infectious diseases, as in
leprosy, diphtheria, typhoid fever, small-pox, scarlet fever, and occasion-
ally in other forms ; {h) the organic poisons, comprising the diffusible
stimulants, such as alcohol and ether, bisulphide of carbon, and naphtha,
and the metallic bodies, such as lead, arsenic, and mercury ; (c) cachectic
conditions, such as occur in anaemia, cancer, tuberculosis, or marasmus
from any cause ; {d) the endemic neuritis or beri-beri ; and (e) lastly,
there are cases in which none of these factors prevail, but the disease sets
in suddenly after overexertion or exposure to cold.
Morbid Anatomy. — In neuritis due to the extension of inflamma-
tion the nerve is usually swollen, infiltrated, and red in color. T\\q in-
flammation may be chiefly perineural or it may pass into the deeper
portion — interstitial neuritis — in which form there is an accumulation of
lymphoid (elements between the nerve bundles. The nerve fibres them-
selves may not appear involved, but there is an increase in the nuclei of
776 DISEASES OF THE NERVOUS SYSTEM.
the sheath of Schwann. The myelin is fragmented, the nuclei of the in-
ternodal cells are swollen, and the axis cylinders present varicosities or
undergo granular degeneration. Ultimately the nerve fibres may be com-
pletely destroyed and replaced by a fibrous connective tissue in which
much fat is sometimes deposited — the lipomatous neuritis of Leyden.
In other instances the condition is termed pm^enchyviatous neuritis, in
which the changes are like those met with in the secondary or Wallerian
degeneration, which follows when the nerve is cut off from its centre.
The medullary substance and the axis cylinders are chiefly involved, the
interstitial tissue being but little altered or only affected secondarily. The
myelin becomes segmented and divides into small globules and granules,
and the axis cylinders become granular, broken, subdivided, and ulti-
mately disappear. The nuclei of the sheath of Schwann proliferate and
ultimately the fibres are reduced to a state of atrophic tubes without a
trace of the normal structure. The muscles connected with the degenerated
nerves usually show marked atrophic changes, and in some instances the
change in the nerve sheath appears to extend directly to the interstitial
tissue of the muscles — the neuritis fascia7is of Eichhorst.
Symptoms, {a) Localized Neuritis. — As a rule the constitutional
disturbances are slight. The most important symptom is pain of a bor-
ing or stabbing character, usually felt in the course of the nerve and in
the parts to which it is distributed. The nerve itself is sensitive to press-
ure, probably, as Weir Mitchell suggests, owing to the irritation of its nervi
nervorum. The skin may be slightly reddened or even cedematous over
the seat of the inflammation. Mitchell has described increase in the tem-
perature and sweating in the affected region, and such trophic disturbances
as effusion into the joints and herpes. The function of the muscle to
which the nerve fibres are distributed is impaired, motion is painful,
and there may be twitchings or contractions. The tactile sensation of
the part may be somewhat deadened, even when the pain is greatly in-
creased. In the more chronic cases of local neuritis, such, for instance, as
follow the dislocation of the humerus, the localized pain, which at first may
be severe, gradually disappears, though some sensitiveness of the brachial
plexus may persist for a long time, and the nerve cords may be felt to be
swollen and firm. The pain is variable — sometimes intense and distress-
ing ; at others not causing much inconvenience. Numbness and formica-
tion may be present and the tactile sensation may be greatly impaired.
The motor disturbances are marked. Ultimately there is extreme atrophy
of the muscles. Contractures may occur in the fingers. The skin may be
reddened or glossy, the subcutaneous tissue cedematous, and the nutrition
of the nails may be defective.
A neuritis limited at first to a peripheral nerve may extend upward —
the so-called ascending or migrating neuritis — and involve the larger
nerve trunks, or even reach the spinal cord, causing subacute myelitis
(Gowers). Thus, in a case reported by James Stewart, a girl of fourteen
NEURITIS. 777
had severe pain in the big toe of the left foot, which gradually extended
up the leg and resisted all treatment until a portion of the sciatic nerve
was removed. A year later she had pain in the little finger of the left
hand, which gradually ascended along the ulnar nerve and required for
its relief division and stretching. It has been suggested that the paralysis
secondary to visceral disease, as of the bladder, may be due to an ascend-
ing neuritis. The inflammation may extend to the nerves of the other
side, either through the spinal cord or its membranes, or without any in-
volvement of the nerve centres, the so-called sympathetic neuritis. The
electrical changes in localized neuritis vary a great deal, depending upon
the extent to which the nerve is injured. The lesion may be so slight
that the nerve and the muscles to which it is distributed may react nor-
mally to both currents ; or it may be so severe that the typical reaction of
degeneration develops within a few days, i. e., the nerve does not respond
to stimulation by either current while the muscle reacts only to the gal-
vanic current and in a peculiar manner. The contraction caused is slow
and lazy, instead of sharp and quick as in the normal muscle, and the AnC
contraction is usually stronger than the CC contraction. Between these
two extremes there are many different grades and a careful electrical
examination is most important as an aid to diagnosis and prognosis.*
The duration varies from a few days to weeks or months. A slight
traumatic neuritis may pass off in a day or two, while the severer cases,
such as follow unreduced dislocation of the humerus, may persist for
months or never be completely relieved.
(b) Multiple Neuritis.— This presents a complex symptomatology. The
following are the most important groups of cases :
(1) Acute Febrile Polyneuritis. — The attack follows exposure to cold
or overexertion, or, in some instances, comes on spontaneously. The on-
set resembles that of an acute infectious disease. There may be a definite
chill, pains in the back and limbs or joints, so that the case may be thought
to be acute rheumatism. The temperature rises rapidly and may reach
103° or 104°. There are headache, loss of appetite, and the general symp-
toms of acute infection. The limbs and back ache. Intense pain in the
nerves, however, is by no means constant. Tingling and formication are
felt in the fingers and toes, and there is increased sensitiveness of the nerve
trunks or of the entire limb. Loss of muscular power, first marked, per-
haps, in the legs, gradually comes on and extends with the features of an
ascending paralysis. In other cases the paralysis begins in the arms. The
extensors of the wrists and the flexors of the ankles are early affected, so
that there is foot and wrist drop. In severe cases there is general loss of
muscular power, producing a flabby paralysis, which may extend to the
muscles of the face and to tlie intercostals, and respiration may be carried
on by the diaphragm alone. The muscles soften and waste rapidly. There
* See under facial paralysis.
778 DISEASES OF THE NERVOUS SYSTEM.
may be only hyperaesthesia with soreness and stiffness of the limbs ; in some
cases, increased sensitiveness with anaesthesia ; in other instances the sen-
sory disturbances are slight. The clinical picture is not to be distin-
guished, in many cases, from Landry's paralysis ; in others, from the sub-
acute myelitis of Duchenne. James Ross concludes from an analysis of
all the reported cases of the former disease that it coincides with multiple
neuritis in general etiology, symptoms, and course. On the other hand,
Ilun, in a very thorough study of a recent case of Landry's paralysis, con-
cludes that it is a separate and distinctive disease.
The course is variable. In the most intense forms the patient may die
in a week or ten days, with involvement of the respiratory muscles or from
paralysis of the heart. As a rule in cases of moderate severity, after per-
sisting for five or six weeks, the condition remains stationary and then slow
improvement begins. The paralysis in some muscles may persist for many
months and contractures may occur from shortening of the muscles, but
even when this occurs the outlook is, as a rule, good, although the pa-
ralysis may have lasted for a year or more.
(2) RGcurring Multiple Neuritis. — Under the term polyneuritis re-
currens Mary Sherwood has described from Eichhorst's clinic two cases in
adults — in one case involving the nerves of the right arm, in the other
both legs. In one patient there were three attacks, in the other two, the
distribution in the various attacks being identical. There has recently
been at my clinic a somewhat similar case — a man, aged thirty-one, who
had, two and a half years ago, widespread paralysis, and who now has a
second attack.
(3) Alcoholic Neuritis. — This, perhaps the most important form of
multiple neuritis, was described in 1822 by James Jackson, Sr., of Bos-
ton, whose account of it is very graphic. Wilks recognized it as alcoholic
paraplegia, but the starting poiiit of the recent researches on the disease
dates from the observation of Dumenil, of Rouen. Of late years our
knowledge of the disease has extended rapidly, owing to the researches of
Huss, Leyden, James Ross, Buzzard, and Henry Hun, It occurs most
frequently in women, particularly steady, quiet tipplers. Its appearance
may be the first revelation to the physician or to the family of habits of
secret drinking. The onset is usually gradual, and may be preceded for
weeks or months by neuralgic pains and tingling in the feet and hands.
Convulsions are not uncommon. Fever is rare. The paralysis gradually sets
in, at first in the feet and legs, and then in tlie hands and forearms. The
extensors are affected more than the flexors, so that there is wrist-drop and
foot-drop. The paralysis may be thus limited and not extend higher in
the limbs. In other instances there is paraplegia alone, while in the most
extreme cases all tlie extremities are involved. In rare instances the facial
muscles and the sphincters are also affected. A case with this distribution
recovered in my wards last year. The sensory symptoms are very variable.
There are cases in which there are numbness and tingling only, without
NEURITIS. 779
great pain. In other cases there are severe burning or boring pains, the
nerve trunks are sensitive, and the muscles are sore when grasped. The
hands and feet are frequently swollen and congested, particularly when
held down for a few moments. The cutaneous reflexes as a rule are pre-
served. The deep reflexes are usually lost.
The course of these alcoholic cases is, as a rule, favorable, and after
persisting for weeks or months improvement gradually begins, the mus-
cles regain their power, and even in the most desperate cases recovery may
follow. The extensors of the feet may remain paralyzed for some time,
and give to the patient a distinctive walk, the so-called steppage gait,
characteristic of peripheral neuritis. It is sometimes known as the pseudo-
tabetic gait, although in reality it could not well be mistaken for the gait
of ataxia. The foot is thrown forcibly forward, the toe lifted high in the
air so as not to trip upon it. The heel is brought down first and then the
entire foot. It is an awkward, clumsy gait, and gives the patient the ap-
pearance of constantly stepping over obstacles. Among the most striking
features of alcoholic neuritis are the mental symptoms. Delirium is com-
mon, and hallucinations with extravagant ideas, resembling somewhat
those of general paralysis. In some cases the picture is that of ordinary
delirium tremens, but the most peculiar and almost characteristic mental
disorder is that so well described by Wilks, in which the patient loses all
appreciation of time and place, and describes with circumstantial details
long journeys which he has recently taken, or tells of pers6ns whom he has
just seen.
(4) Multiple Neuritis in the Infectious Diseases. — These have been al-
ready referred to, particularly in diphtheria, in which it is most common.
The peripheral nature of the lesion in these instances has been shown by
post-mortem examination. The outlook is usually favorable and, except
in diphtheria, fatal cases are uncommon. Multiple neuritis in tuberculosis,
diabetes, and sypliilis is of the same nature, probably due to toxic materials
absorbed into the blood.
(5) Arsenical and Saturnine Neuritis. — The arsenical neuritis is not
common ; only a single instance of it has come under my observation. No
case to my knowledge has followed the use of Fowler's solution in my
ward or dispensary practice, although I am in the habit of giving in
chorea and anaemia doses which might be regarded as excessive. The
most common causes are accidental poisoning, as in the cases reported by
Mills. In a case of E. G. Cutler the patient got the arsenic from green-
paper tags, which he was in the habit of putting in his mouth. The gen-
eral symptoms are not unlike those of alcoholic paralysis ; the weakness of
the extensors is marked and the steppage gait characteristic. The neuritis
due to lead will be discussed in the consideration of lead poisoning. The
special involvement of the motor nerves and the great frequency of the
occurrence of wrist-drop are the peculiarities of this form.
A similar form of neuritis is caused by the bisulphide of carbon.
780 DISEASES OF THE NERVOUS SYSTEM.
(6) Endemic ITeuritis ; Beri-heri. — This is a widely spread disease in
parts of India, and in China and Japan. To Sheube and Baelz are due
the credit of determining its true nature. It is probably due to a micro-
organism. Food appears also to have a large share in its causation and it
has been attributed to a fish diet. Some have thought it might be due
to the presence of parasites in the intestines, but there are no grounds for
this belief. There are several types of cases. In the acute pernicious
form the nervous phenomena are not so marked. There are fever, anaemia,
and general anasarca. In another group of cases there are numbness,
loss of tendon reflexes, areas of anaesthesia, and muscular atrophy and
anasarca. In other cases the paralysis and atrophy are the most promi-
nent symptoms and the clinical picture is that of a rapidly progressing
multiple neuritis with sensory and motor disturbances. The mortality
varies from three or four to fifty per cent. Great difference of opinion
still prevails concerning the cause of the disease. Special interest has been
aroused in the subject in this countr}", owing to the fact that J. J. Putnam
has described a similar disorder among the N^ew England fishermen who fre-
quent the Grand Banks. It occurs in epidemic form, and has, as prominent
symptoms, general oedema, shortness of breath, and sensory disturbances
with paralysis. In other instances, the paralysis is more extensive and
proves fatal. In 1881 and 1889 there were epidemics among the crews of
vessels fishing in this region. Birge describes eleven cases which occurred
on one vessel in a crew of thirteen, two of whom died. One patient of
this crew^ I saw with F. C. Shattuck, in the Massachusetts General Hos-
pital, with the well-marked symptoms of multiple neuritis. The disease
also exists in the West Indies, whence cases have come to this country
(Seguin).
Diagnosis. — The electrical condition in multiple neuritis is thus
described by Allen Starr : " The excitability is very rapidly and markedly
changed ; but the conditions Avhich have been observed are quite various.
Sometimes there is a simple diminution of excitability, and then a very
strong faradic or galvanic current is needed to produce contractions.
Frequently all faradic excitability is lost and then the muscles contract to
a galvanic current only. In this condition it may require a very strong
galvanic current to produce contraction, an<i thus far it is quite pathog-
nomonic of neuritis. For in anterior polio-myelitis, where the muscles re-
spond to galvanism only, it does not require a strong current to cause a
motion until some months after the invasion.
" The action of the different poles is not uniform. In many cases
the contraction of the muscle when stimulated with the positive pole
is greater than when stimulated with the negative pole, and the co;i-
tractions may be sluggish. Then the reaction of degeneration is pres-
ent. But in some cases the normal condition is found and the nega-
tive pole produces stronger contractions than the positive pole. A loss
of faradic irritability and a marked decrease in the galvanic irritability of
NEUROMATA. 781
the muscle and nerve are therefore important symptoms of multiple
neuritis." *
There is rarely any difficulty in distinguishing the alcohol cases. The
combination of wrist and foot drop with congestion of the hands and feet,
and the peculiar delirium already referred to, is quite characteristic. The
rapidly advancing cases with paralysis of all extremities, often reaching
to the face and involving the sj^hincters, are more commonly regarded as
of spinal origin, but the general opinion seems to point strongly to the
fact that all such cases are peripheral. The less acute cases, in which the
paralysis gradually involves the legs and arms with rapid wasting, simu-
late closely and are usually confounded with the subacute atrophic spinal
paralysis of Duchenne. The diagnosis from locomotor ataxia is rarely
difficult. The stejopage gait is entirely different from that of tabes. There
is rarely positive incoordination. The patient can usually stand well v/ith
the eyes closed. Foot-drop is not common in locomotor ataxia. The
lightning pains are absent and there are no pupillary symptoms. The eti-
ology, too, is of moment. The patient is recovering from a paralysis which
has been more extensive, or from arsenical poisoning or has diabetes.
Treatment. — Rest in bed is essential. In the acute cases with fever,
the salicylates and antipyrin are recommended. To allay the intense
pain morphia or the hot applications of lead water and laudanum are
often required. Great care must be exercised in treating the alcoholic
form, and the attendant must not allow himself to be deceived by the
statements of the relatives. It is sometimes exceedingly difficult to get a
history of spirit-drinking. In the alcoholic form it is well to reduce the
stimulants gradually. If there is any tendency to bed-sore an air-bed
should be used or the patient placed in a continuous bath. Gentle fric-
tion of the muscles may be applied from the outset, and in the later stages,
when the atrophy is marked and the pains have lessened, massage is prob-
ably the most reliable means at our command. Contractures may be
gradually overcome by passive movements and extension. Often, with
the most extreme deformity from contracture, recovery is, in time, still
possible. The interrupted current is useful when the acute stage is
passed.
Of internal remedies, strychnia is of value and may be given in in-
creasing doses. Arsenic also may be employed, and if there is a history
of syphilis the iodide of potassium and mercury may be given.
II. NEUROMATA.
Tumors situated on nerve fibres may consist of nerve substance proper,
the true neuromata, or of fibrous tissue, the false neuromata. The true
* Lectures on Neuritis, Medical Record, New York, 1887.
782 DISEASES OF THE NERVOUS SYSTEM.
neuroma usually contains nerve fibres only, or in rare instances ganglion
cells. Cases of ganglionic or medullary neuroma are extremely rare ;
some of them, as Lancereaux suggests, are undoubtedly instances of mal-
formation of the brain substance. In other instances, as in the case which
I reported,* the tumor is, in all probability, a glioma with cells closely re-
sembling those of the central nervous system. The true fascicular neu-
roma occurs in the form of the small subcutaneous painful tumor — tuber-
cula dolorosa — which is situated on the nerves of the skin about the
joints, sometimes on the face or on the breast. It is not always made up
of nerve fibres, but may be, as shown by Hoggan, an adenomatous growth
of the sweat glands.
The true neuromata, as a rule, are not painful, and occasionally are
found associated with the nerve fibres in various regions. Those which
develop at the ends and along the course of the nerves of the stump after
amputation consist of connective tissue and of medullated and non-medul-
lated nerve fibres. The most remarkable form is the plexiform neuroma,
in which the various nerve cords are occupied by many hundreds of
tumors. The cases are usually congenital. The tumors occur in all the
nerves of the body. One of the most remarkable is that described by
Prudden, the specimens of which are in the medical museum of Columbia
College, N"ew York. There were over 1,182 distinct tumors distributed on
the nerves of the body. Prudden f has collected forty-one cases from the
literature, in a majority of which the peripheral nerves were affected.
Neuromata rarely cause symptoms, except the subcutaneous painful
tumor or those in the amputation stump. Here they may be very pain-
ful and cause great distress. Motor symptoms are sometimes present,
particularly a constant twitching. Epilepsy has sometimes been asso-
ciated, and relief has followed removal of the growths.
The only available treatment is excision. The subcutaneous painful
tumor does not return, and excision completely relieves the symjotoms.
On the other hand, the amputation neuromata may recur.
III. DISEASES OF THE CRANIAL NERVES.
I. Olfactory Nerve.
The functions of this nerve may be disturbed at its peripheral ending,
at the l)nlb, in the course of the nerve, or at the central origin in the brain.
The disturbances may be manifested in subjective sensations of smell,
complete loss of the sense, and occasionally in hypersesthesia.
(a) Subjective Sensations ; Paros7nia. — Hallucinations of this kind are
found in the insane and in epilepsy. The aura may be represented by an
* Journal of Anatomy and Physiology, vol. xv.
f American Journal of the Medical Sciences, vol. Ixxx.
DISEASES OF THE CRANIAL NERVES. 783
unpleasant odor, described as resembling chloride of lime, burning rags^
or feathers. In a few cases with these subjective sensations tumors have
been found in the hippocampal lobules. In rare instances, after injury of
the head the sense is perverted — odors of the most different character may
be alike, or the odor may be changed, as in a patient noted by Morell
Mackenzie, who for some time could not touch cooked meat, as it smelt
to her exactly like stinking fish.
(b) Increased sensitiveness, or hyperosmia, occurs chiefly in nervous,
hysterical women; in whom it may sometimes be developed so greatly that,
like a dog, they can recognize the difference between individuals by the
odor alone.
(c) Anosmia; Loss of the Sense of Smell. — This may be produced by:
(1) Affections of the termination of the nerve in the mucous membrane,
which is perhaps the most frequent cause. It is by no means uncommon
in association with chronic nasal catarrh and polypi. In paralysis of the
fifth nerve, the sense of smell may be lost on the affected side, owing to
interference with the secretion.
It is doubtful whether the cases of loss of smell following the inhala-
tions of very foul or strong odors should come under this or under the
central division.
(2) The lesions of the bulb or of the nerves. In falls or blows, in
caries of the bones, and in meningitis or tumor, the bulbs or the nerve
trunks may be involved. After an injury to the head the loss of smell
may be the only symptom. Mackenzie notes a case of a surgeon who was
thrown from his gig and lighted on his head. The injury was slight, but
the anosmia which followed was persistent. In locomotor ataxia the sense
of smell may be lost, due possibly to atrophy of the nerves.
(3) Lesions of the olfactory centre. There are congenital cases in
which the nerve structures have not been developed. Cases have been re-
ported by Beevor, Hughlings Jackson, and others, in Avhich this symp-
tom has been associated with disease in the hemisphere. The centre for
the sense of smell is placed by Ferrier in the uncinate gyrus.
To test the sense of smell the pungent bodies, such as ammonia, which
act upon the fifth nerve, should not be used, but such substances as cloves,
peppermint, and musk. This sense is readily tested as a routine matter in
brain cases by having two or three bottles containing the essential oils.
In all instances a rhinoscopical examination should be made, as the con-
dition may be due to local, not central causes. The treatment is unsatis-
factory even in the cases due to local lesions in the nostrils.
II. Optic Nerve and Tract.
(1) Lesions of the Retina.
These are of importance to the physician, and information of the
greatest value may be obtained by a systematic examination of the eye-
784: DISEASES OF THE NERVOUS SYSTEM.
grounds. Only a brief reference can here be made to the more impor-
tant of the appearances.
(a) Retinitis. — This occurs in certain general affections, more particu-
larly in Bright's disease, syphilis, leukaemia, and anaemia. The common
feature in all these states is the occurrence of haemorrhage and the de-
velopment of opacities. There may also be a diffuse cloudiness due to
effusion of serum. The haemorrhages are in the layer of nerve fibres.
They vary greatly in size and form, but often follow the course of vessels.
When recent the color is bright red, but they gradually change and old
haemorrhages are almost black. The white spots are due either to fibrin-
ous exudate or to fatty degeneration of the retinal element, and occasion-
ally to accumulation of leucocytes or to a localized sclerosis of the retinal
elements. The more important of the forms of retinitis to be recognized
are :
Albuminuric retinitis, which occurs in chronic nephritis, particularly
in the interstitial or contracted form. The percentage of cases affected
is from fifteen to twenty-five. There are instances in which these retinal
changes are associated with the granular kidney at a stage when the
amount of albumen may be slight or transient ; but in all such instances
it will be found that there is a marked arterio-sclerosis. Gowers recog-
nizes a degenerative form (most common), in which, with the retinal
changes, there may be scarcely any alteration in the disk ; a haemorrhagic
form, with many haemorrhages and but slight signs of infiammation ; and
an inflammatory form, in which there is much swelling of the retina and
obscuration of the disk. It is noteworthy that in some instances the in-
flammation of the optic nerve predominates over the other retinal changes
and one may be in doubt for a time whether the condition is really asso-
ciated with the renal changes or dependent upon intracranial disease.
Syphilitic Retiiiitis. — In the acquired form this is less common than
choroiditis. In inherited syphilis retinitis pigmentosa is sometimes met
with.
Retinitis in Ancemia. — It has long been known that a patient may
become blind after a large haemorrhage, either suddenly or within two or
three days, and in one or both eyes. Occasionally the loss may be perma-
nent and complete. In some of these instances a neuro-retinitis has been
found, probably sufficient to account for the symptoms. In the more
chronic anaemias, particularly in the pernicious form, retinitis is common,
as determined first by Quincke.
In malaria retinitis or neuro-retinitis may be present, as noted by
Stephen Mackenzie. It is seen only in the chronic cases with anaemia,
and in my experience is not nearly so common proportionately as in per-
nicious anaemia. Of many instances which have come under my observa-
tion of severe malarial anaemia, particularly at the Philadelphia Hospital,
there were only two with retinal haemorrhages.
Leukemic Retinitis. — In this affection the retinal veins are large
DISEASES OF THE CRANIAL NERVES. 785
and distended ; there is also a peculiar retinitis, as described by Liebreich.
It is not very common. Of the seventeen cases of leukaemia which have
come under my observation, retinitis existed in only three of the ten in
which the eye-grounds were examined. There are numerous haemor-
rhages and white or yellow areas, which may be large and prominent.
In one of my cases the retina post mortem was occupied by many small,
opaque, white spots, looking like little tumors, the larger of which had a
diameter of nearly two millimetres. In Case 13 of my series the leukaemia
was diagnosed by Norris and De Schweinitz, at wdiose clinic the patient
had applied on account of failing vision, from the condition of the eye-
grounds alone.
Retinitis is also found occasionally in diabetes, in purpura, in chronic
lead poisoning, and sometimes as an idiopathic affection.
{h) Functional Disturbances of the Retina, (1) Toxic Amaurosis. —
This occurs in uraemia and may follow convulsions or come on independ-
ently. Thus, a patient who had become suddenly blind the previous day,
was led into one of my w^ards at the Montreal General Hospital. He had
had no special symptoms, but examination showed extensive cardio-vas-
cular changes. The urine was albuminous. The ophthalmoscopic exam-
ination was negative. The condition, as a rule, persists only for a day
or two. This form of amaurosis occurs in poisoning by lead and occa-
sionally by quinine. It seems more probable that the poisons act on the
centres and not on the retina.
(2) Hysterical Amaurosis. — More frequently this is loss of acuteness
of vision — amblyopia — but the loss of sight in one or both eyes may
apparently be complete. The condition will be mentioned subsequently
under hysteria.
(3) Tobacco Amblyopia. — The loss of sight is usually gradual, equal in
both eyes, and affects particularly the centre of the field of vision. The
eye-grounds may be normal, but occasionally there ' is congestion of the
disks. On testing the color fields a central scotoma for red and green is
found in all cases. Ultimately, if the use of tobacco is continued, organic
changes may develop with atrophy of the disk.
(4) Niylit-blindness — nyctalopia — the condition in which objects are
clearly seen during the day or by strong artificial light, but become in-
visible in the shade or in twilight, and hemeralopia, in which objects
cannot be clearly seen without distress in daylight or in a strong artificial
light, but are readily seen in a deep shade or in twilight, are functional
anomalies of the retina which rarely come under the notice of the
physician.
(5) Retinal hypermsthesia is sometimes seen in hysterical women, but
is not fouTif] frequently in actual retinitis. I have seen it once, however,
in albuminuric retinitis and once, in a marked degree, in a patient with
aortic insufTicioncy, in whose retinae there were no signs other than the
throbbing arteries.
786 DISEASES OF THE NERVOUS SYSTEM.
(2) Lesions of the Optic Nerve.
(a) Optic Neuritis {Papillitis', Choked Disk). — lu the first stage there
is congestion of the disk and the edges are bkirred and striated. In the
second stage, the congestion is more marked, the swelling increases, the
striation also is more visible. The physiological cupping disappears and
haemorrhages are not uncommon. The arteries present little change, the
veins are dilated, and the disk may swell greatly. In slight grades of in-
flammation the swelling gradually subsides and occasionally the nerve
recovers completely. In instances in which the swelling and exudate are
very great, the subsidence is slow, and when it finally disappears there is
complete atrophy of the nerve. The retina not infrequently participates
in the inflammation, which is then a neuro-retinitis.
This condition is of the greatest importance in diagnosis. It may exist
in its early stages without any disturbance of vision, and even with exten-
sive papillitis the sight may for a time be good.
Optic neuritis is seen occasionally in anaemia and lead poisoning, more
commonly in Bright's disease as neuro-retinitis. It occurs occasionally as
a primary idiopathic affection. The frequent connection with intracranial
disease, particularly tumor, makes its presence of great value to practi-
tioners. The nature of the growth is without influence. In over ninety
per cent of such instances the papillitis is bilateral. It is also found in
meningitis, either the tuberculous or the simple form. In meningitis it is
easy to see how the inflammation may extend down the nerve sheaths. In
the case of tumor it was thought at first that a choked disk resulted from
increased pressure within the skull. It is noAV more commonly regarded,
however, as a descending neuritis.
(b) Optic Atrophy. — This may be: (1) A primary affection. Some of
the cases have been hereditary and have come on in all the males of a
family shortly after puberty. A large number of the cases of primary
atrophy are associated with spinal disease, particularly locomotor ataxia.
Other causes which have been assigned for the primary atrophy are cold,
sexual excesses, diabetes, the specific fevers, alcohol, and lead.
(2) Secondary atrophy results from cortical lesions, pressure on the
chiasma or on the nerves, or, most commonly of all, is a sequence of pa-
pillitis.
The ophthalmoscopic appearances are different in the cases of primary
and secondary atrophy. In the former, the disk has a gray tint, the edges
are well defined, and the arteries look almost normal ; whereas in the con-
secutive atrophy the disk has a staring opaque-white aspect, with irregular
outlines, and the arteries are very small.
The symptom of optic atrophy is loss of sight, proportionate to the
damage in the nerve. The change is in three directions : " (1) Diminished
acuity of vision ; (2) alteration in the field of vision ; and (3) altered per-
ception of color." (Gowers.) The outlook in primary atrophy is bad ; the
DISEASES OF THE CRANIAL NERVES. 787
majority of cases go on to complete blindness. In the consecutive form
there is greater chance of retention of slight vision.
(3) Affections of the Chiasma and Tract.
At the chiasma the optic nerves undergo partial decussation. Each
optic tract, as it joins the chiasma, contains nerve fibres which supply half
of the retina of either eye. Thus, of the fibres of the right tract, part pass
the chiasma without decussating and supply the temporal half of the right
retina, the other and larger portion of the fibres of the tract decussate in
the chiasma and join the left optic nerve, supplying the nasal half of the
retina on the other side. The fibres which cross are in the middle portion
of the chiasma, while the direct fibres are on each side. The following are
the most important changes which ensue in lesions of the tract and of the
chiasma :
{a) Unilateral Affection of Tract (Fig. 1 B). — If right this produces loss
of function in the temporal half of the retina on the right side, and on the
nasal half of the retina on the left side, so that there is only half vision,
and the patient is blind to objects on the left side. This is termed ho-
monymous hemianopia or lateral hemianopia. The fibres passing to the
right half of each retina being involved, necessarily the left half of each
visual field is blind. The hemianopia may be partial and only a portion
of the half field may be lost. The affected visual fields may have the nor-
mal extent, but in some instances there is considerable reduction. The
color vision is, as a rule, lost in the half field — hemiachromatopia — but the
half vision for color may be lost in central disease without any change in
the field for white. When the left half of one field and the right half of
the other, or vice versa, are blind, the condition is known as heteronymous
hemianopia.
{b) Disease of the Chiasma. — (1) A lesion involves, as a rule, chiefly
the central portion, in which the decussating fibres pass which supply the
inner or nasal halves of the retinae, producing in consequence loss of vision
in the outer half of each field, or what is known as temporal hemianopia
(Fig. 1 //).
(2) If the lesion is more extensive it may involve not only the central
portion, but also the direct fibres on one side of tlie commissure, in which
case there would be total blindness in one eye and temporal hemianopia in
the other.
(3) Still more extensive disease is not infrequent from pressure of tu-
mors in this region, the whole chiasma is involved, and total blindness
results. The different stages in the process may often be traced in a
single case from temporal hemianopia, then complete blindness in one
eye with temporal hemianopia in the other, and finally complete blind-
ness.
(4) A limited lesion of the outer part of each chiasma involves only the
direct fibres passing to the temporal halves of the retinas and inducing
60
788
DISEASES OF THE NERVOUS SYSTEM.
blindness in the nasal field, or, as it is called, nasal hemianopia. This, of
course, is extremely rare.
Fio. 1. — The optic and visual tracts (Starr). iV", Lesion causing nasal hemianopia.
J\ Lesions causing temporal hemianopia. //, Lesion causing bilateral heterony-
mous hemianopia. B^ Lesion of tract causing homonymous hemianopia.
(4) Affections of the Tract and Centres.
The optic tract crosses the crus to the hinder part of the optic thala-
mus and divides into two portions, one of which goes to the thalamus and
external geniculate bodies and to the anterior quadrigeminal bodies. From
DISEASES OF THE CRANIAL NERVE&. 789
these parts fibres pass into the posterior part of the internal capsule and
enter the occipital lobe, forming the fibres of the optic radiation (Fig. 1),
which terminate in and about the cuneus, the region of the visual percep-
tive centre. The fibres of the other division of the tract pass to the in-
ternal geniculate bodies and to the posterior quadrigeminal body. It is
still held by some physiologists that the cortical visual centre is not con-
fined to the occipital lobe alone, but embraces the occipito-angular region.
A lesion of the fibres of the optic tract anywhere between the cortical
centre and the chiasma will produce lateral hemianopia. The lesion may
be situated : (a) In the tract itself, (b) In the region of the thalamus and
the corpora quadrigemina, into which the larger part of each tract enters.
(c) A lesion of the fibres passing from the corpora quadrigemina to the oc-
cipital lobe. This may be either in the hinder part of the internal capsule
or the white fibres of the optic radiation, (d) Lesion of the cuneus. Bi-
lateral disease of the cuneus may result in total blindness, (e) There is
clinical evidence to show that lesion of the angular gyrus may be associ-
ated with visual defect, not so often hemianopia as crossed amblyopia?
dimness of vision in the opposite eye, and great contraction in the
field of vision. Lesions in this region are associated with mind blind-
ness, a condition in which there is failure to recognize the nature of ob-
jects.
The effects of lesions in the optic nerve in different situations from the
retinal expansion to the brain cortex are as follows : (1) Of the optic nerve
— total blindness of the corresponding eye ; (2) of the optic chiasma,
either temporal hemianopia, if the central part alone is involved, or
nasal hemianopia, if the lateral region of each chiasma is involved ; (3)
lesion of the optic tract between the chiasma and the geniculate bod-
ies, produces lateral hemianopia ; (4) lesion of the central fibres of the
nerve between the geniculate bodies and the cerebral cortex produces
lateral hemianopia; (5) lesion of the cuneus causes lateral hemianopia;
and (G) lesion of the angular gyrus may be associated with hemianopia,
sometimes crossed amblyopia, and the condition known as mind blind-
ness.
Diagnosis. — The student or practitioner must have a clear idea of
the physiology of the nerve centres before he can appreciate the symptoms
or undertake the diagnosis of lesions of the optic nerve. Having deter-
mined the presence of hemianopia, the question arises as to the situation
of the lesion, whether in the tract between the chiasma and the geniculate
bodies or in the central portion of the fibres between these bodies and the
visual centres. This can be determined in some cases by the test known
as Wernicke's hemiopu pupillary inaction. The pupil reflex depends on
the integrity of the retina or receiving membrane, on the fibres of the op-
tic nerve and tract which transmit the impulse, and the nerve centre in the
geniculate bodies which receives the impression and transmits it to the
third nerve along which the motor impulses pass to the iris. If a bright
790 DISEASES OF THE NERVOUS SYSTEM.
light is thrown into the eye and the pupil reacts, the integrity of this re-
flex arc is demonstrated. It is possible in cases of lateral hemianopia so
to throw the light into the eye that it falls upon the blind half of the
retina. If when this is done the pupil contracts, the indication is that
the reflex arc above referred to is perfect, by which we mean that the
optic nerve fibres from the retinal expansion to the centre, the centre
itself, and the third nerve are uninvolved. In such a case the conclu-
sion would be justified that the cause of the hemianopia was central;
that is, situated behind the geniculate bodies, either in the fibres of the op-
tic radiation or in the visual cortical centres. If, on the other hand, when
the light is carefully thrown on the hemiopic half of the retina, the pupil
remains inactive, the conclusion is justifiable that there is interruption in
the path between the retina and the geniculate bodies, and that the hemi-
anopia is not central, but dependent upon a lesion situated in the tract.
This test of Wernicke's is sometimes difficult to obtain. It is best per-
formed as follows : " The patient being in a dark or nearly dark room
with the lamp or gas-light behind his head in the usual position, I bid him
look over to the other side of the room, so as to exclude accommodative
iris movements (which are not necessarily associated with the reflex).
Then I throw a faint light from a plane mirror or from a large concave
mirror held well out of focus upon the eye and note the size of the pupil.
With my other hand I now throw a beam of light, f ocussed from the lamp
by an ophthalmoscopic mirror, directly into the optical centre of the eye ;
then laterally in various positions, and also from above and below the
equator of the eye, noting the reaction at all angles of incidence of the
ray of light." (Seguin.)
The significance of hemianopia varies. There is a functional hemi-
anopia associated with migraine and hysteria. In a considerable pro-
portion of all cases there are signs of organic brain-disease. Hemiplegia
is common and the loss of power and blindness are on the same side.
Thus, a lesion in the left hemisphere involving the motor tract produces
right hemiplegia, and when the fibres of the optic radiation are involved
in the internal capsule, there is also left lateral hemianopia, so that objects
in the field of vision to the right are not perceived. Hemianaesthesia is
not uncommon, owing to the close association of the sensory and visual
tracts at the posterior part of the internal capsule. Certain forms of
aphasia also occur in many of the cases.
III. Motor Nerves of the Eyeball.
Third Nerve. — Arising from the floor of the aqueduct of Sylvius, the
nerve j)asses through the crus at the side of which it emerges. Passing
along the wall of the cavernous sinus, it enters the orbit through the
sphenoidal fissure and supplies, by its superior branch, the levator palpe-
brge superioris and the superior rectus, and by its inferior branch the in-
DISEASES OF THE CRANIAL NERVES. 791
ternal and inferior recti muscles and the inferior oblique. It also suj)-
plies the ciliary muscle and the constrictor of the iris. Lesions may
affect the centre or the nerve in its course and cause either paralysis or
spasm.
Paralysis. — A nuclear lesion is usually associated with the disease of
the centres for the other eye muscles, producing a condition of gen-
eral ophthalmoplegia. More commonly the nerve itself is involved
in its course, either by meningitis, gummata, or aneurism, or is at-
tacked by neuritis, as in diphtheria and locomotor ataxia. Complete
paralysis of the third nerve is accompanied by the following symp-
toms:
Paralysis of all the muscles, except the superior oblique and external
rectus, by which the eye can be moved outward and a little downward and
inward. There is divergent strabismus. There is ptosis or drooping of
the upper eyelid, owing to paralysis of the levator palpebrae. The pupil
is of medium size. It does not contract to light, and the power of accom-
modation is lost. The most striking features of this paralysis are the ex-
ternal strabismus, with diplopia or double vision, and the ptosis. In very
many cases the affection of the third nerve is partial. Thus the levator
palpebrae and the superior rectus may be involved together, or the ciliary
muscles and the iris may be affected and the external muscles may
escape.
There is a remarkable form of recurring oculo-motor paralysis affect-
ing chiefly women, and involving all the branches of the nerve. In some
cases the attacks have come on at intervals of a month ; in others a much
longer period has elapsed. The attacks may persist throughout life.
They are sometimes associated with pain in the head and sometimes with
migraine. Mary Sherwood has collected from the literature twenty-three
cases.
Ptosis is a common and important symptom in nervous affections.
We may here briefly refer to the conditions under which it may occur :
{a) A congenital, incurable form, which is frequently seen ; {b) the form
associated with definite lesion of the third nerve, either in its course or
at its nucleus. This may come on with paralysis of the superior rectus
alone or with paralysis of the internal and inferior recti as well, (c)
There are instances of complete or partial ptosis associated with cere-
bral lesions without any other branch of the third nerve being par-
alyzed. The position of the cortical centre is as yet unknown. {d)
Hysterical ptosis, which is double and occurs with other hysterical symp-
toms, {e) Sympathetic or pseudo-ptosis is associated with symptoms of
vaso-motor palsy, such as elevation of the temperature on the affected
side with redness and cedema of the skin. Contraction of the pupils
exists on the same side and the eyeball appears rather to have shrunk into
the orbit. (/) In idiopathic muscular atrophy, when the face muscles are
involved, tliore may be marked bilateral ptosis. And, lastly, in weak, deli-
792 DISEASES OF THE NERVOUS SYSTEM.
cate women there is often to be seen a transient ptosis, particularly in the
morning.
Among the most important of the symptoms of the third-nerve paral-
ysis are those which relate to the ciliary muscle and iris.
Cycloplegia^ paralysis of the ciliary muscle, causes loss of the power
of accommodation. Distant vision is clear, but near objects cannot be
properly seen. In consequence the vision is indistinct, but can be re-
stored by the use of convex glasses. This may occur in one or in both eyes ;
in the latter case it is usually associated with disease in the nuclei of the
nerve. Cycloplegia is an early and frequent symptom in diphtheritic
paralysis and occurs also in tabes.
Iridoj^legia^ or paralysis of the iris, occurs in three forms (Gowers).
{a) Accommodative iridoplegia, in which the pupil does not diminish
in size during the act of accommodation. To test for this the patient
should look first at a distant and then at a near object in the same line of
vision.
(b) Reflex IridopJegia. — The path for the iris reflex is along the optic
nerve and tract to the geniculate bodies, then to the nucleus of the third
nerve, and along the trunk of this nerve to the ciliary ganglion, and so
through the ciliary nerves to the eyes. Each eye should be tested sepa-
rately, the other one being covered. The patient should look at a distant
object in a dark part of the room ; then a light is brought suddenly in
front of the eye at a distance of three or four feet, so as to avoid the effect
of accommodation. Loss of this iris reflex with retention of the accom-
modation contraction is known as the Argyll -Kobertson pupil.
(c) Loss of the Skin Reflex. — If the skin of the neck is pinched or
pricked the pupil dilates reflexly, the afferent impulses being conveyed
along the cervical sympathetic. Erb pointed out that this skin reflex is
lost usually in association with the reflex contraction, but the two are not
necessarily conjoined. In iridoplegia the pupils are often small, particu-
larly in spinal disease, as in the characteristic small pupils of tabes — spinal
myosis. Iridoplegia may coexist with a pupil of medium size.
Inequality of the pupils — anisocoria — is not infrequent in progressive
paresis and in tabes. It may also occur in perfectly healthy individuals.
Spasm,. — Occasionally in meningitis and in hysteria there is spasm of
the muscles supplied by the third nerve, particularly the internal rectus
and the levator palpebrae. The clonic rhythmical spasm of the eye mus-
cles is known as nystagmus^ in which there is usually a bilateral, rhythmi-
cal, involuntary movement of the eyeballs. The condition is met with in
many congenital and acquired brain lesions, in albinism, and sometimes
in coal-miners.
Fourth Nerve. — This supplies the superior oblique muscle. In its
course around the outer surface of the crus and in its passage into the
DISEASES OP THE CRANIAL NERVES. 'T'OS
orbit it is liable to be compressed by tumors, by aneurism or in the exu-
dation of basilar meningitis. Its nucleus in the upper part of the fourth
ventricle may be involved by tumors or undergo degeneration with the
other ocular nuclei. The superior oblique muscle acts in such a way as
to direct the eyeball downward and rotates it slightly. The paralysis
causes defective downward and inward movement, often too slight to be
noticed. The head is inclined somewhat forward and toward the sound
side, and there is double vision when the patient looks down, as in de-
scending stairs.
Sixth Nerve. — This nerve emerges at the junction of the pons and
medulla, then, passing forward, it enters the orbit and supplies the external
rectus muscle. It is affected by meningitis at the base or by gummata or
other tumors, and sometimes by cold. There is internal strabismus, and
the eye cannot be turned outward. Diplopia occurs on looking toward
the paralyzed side.
" AVhen the nucleus is affected there is, in addition to paralysis of the
external rectus, inability of the internal rectus of the opposite eye to turn that
eye inwards. As a consequence of this the axes of the eyes are kept parallel
and both are conjugately deviated to the opposite side, away from the side
of lesion. The reason of this is that the nucleus of the sixth nerve sends
fibres up in the pons to that part of the nucleus of the opposite third
nerve which supplies the internal rectus. ^Ye thus have paralysis of the
internal rectus without the nucleus of the third nerve being involved,
owing to its receiving its nervous impulses for parallel movement from
the sixth nucleus of the opposite side. As the sixth nucleus is in such
proximity to the facial nerve in the substance of the pons, it is frequently
found that the whole of the face on the same side is paralyzed, and gives
the electrical reaction of degeneration, so that with a lesion of the left
sixth nucleus there is conjugate deviation of both eyes to the right — i. e.,
paralysis of the left external and the right internal rectus, and sometimes
complete paralysis of the left side of the face." (Beevor.)
General Features of Paralysis of the Motor Nerves of the Eye. — Gowers
divides them into five groups :
(a) Liynitation of Movement. — Thus, in paralysis of the external rec-
tus, the eyeball is turned in by the contraction of the internal rectus and
cannot be moved outward. When the paralysis is incomplete the move-
ment is deficient in proportion to the degree of the palsy.
{h) Strabismus. — The axes of the eyes do not correspond. Thus, par-
alysis of the internal rectus causes a divergent squint; of the external
rectus, a convergent squint. The deviation of the axis of tlie affected eye
from parallelism with the other is called the primary deviation.
{c) Secondary Deviation. — If, while the patient is looking at an ob-
ject, the sound eye is covered, so that he fixes the object looked at with
the affected eye only, the sound eye is moved still further in the same di-
794 DISEASES OF THE NERVOUS SYSTEM.
rection — e. g., outward — with paralysis of the opposite internal rectus.
This is known as secondary deviation. It depends upon the fact that, if
two muscles are acting together, when one is weak and an effort is made
to contract it, the increased effort — innervation — acts powerfully upon the
other muscle, causing an increased contraction.
(d) Erroneous Projection. — " We judge of the relation of external
objects to each other by the relation of their images on the retina ; but
we judge of their relation to our own body by the position of the eyeball
as indicated to us by the innervation we give to the ocular muscles "
(Gowers). AVith the eyes at rest in the mid-position, an object at which
we are looking is directly opposite our face. Turning the eyes to one
side, w^e recognize that object in the middle of the field or to the side of
this former position. We estimate the degree by the amount of move-
ment of the eyes, and when the object moves and we follow it we judge
of its position by the amount of movement of the eyeballs. When one
ocular muscle is weak, the increased innervation gives the impression of
a greater movement of the eye than has really taken place. The mind, at
the same time, receives the idea that the object is further on one side
than it really is, and in an attempt to touch it the finger may go beyond
it. As the equilibrium of the body is in a large part maintained by a
knowledge of the relation of external objects to it obtained by the action
of the eye muscles, this erroneous projection resulting from paralysis dis-
turbs the harmony of these visual impressions and may lead to giddiness
— ocular vertigo.
(e) Double Vision. — This is one of the most disturbing features of
paralysis of the eye muscles. The visual axes do not correspond, so that
there is a double image — diplopia. That seen by the sound eye is termed
the true image ; that by the paralyzed eye, the false. In simple or homon-
ymous diplopia the false image is " on the same side of the other as the eye
by which it is seen." In crossed diplopia it is on the other side. In con-
vergent squint the diplopia is simple ; in divergent it is crossed.
Ophthalmoplegia. — Under this term is described a chronic progressive
paralysis of the ocular muscles. Two forms are recognized — ophthalmo-
plegia externa and ophthalmoplegia interna. The conditions may occur
separately or together and are described by Gowers under nuclear ocular
palsy.
Ophthalmoplegia Externa. — The condition is one of more or less com-
plete palsy of the external muscles of the eyeball, due usually to a slow
degeneration in the nuclei of the nerves, but sometimes to pressure of
tumors or to basilar meningitis. It is often but not necessarily associated
with ophthalmoi)lcgia interna. Siemerling, in the recent monograph in
wliich he has analyzed the material (eight cases) left by the late Prof.
Westphal, states that sixty-two cases are on record. In only eleven of
these could syphilis be positively determined. The levator muscles of tlie
eyelids and the superior recti are first involved, and gradually the other
DISEASES OP THE CRANIAL NERVES. 795
muscles, so that the eyeballs are fixed and the eyelids droop. There is
sometimes slight protrusion of the eyeballs. The disease is essentially
chronic and may last for many years. It is found particularly in association
with general paralysis, locomotor ataxia, and in progressive muscular
atrophy. Mental disorders were present in eleven of the sixty-two cases.
With it may be associated atrophy of the optic nerve and affections of
other cranial nerves. Occasionally, as noted by Bristowe, it may be func-
tional.
Ophthalmoplegia Interna. — Jonathan Hutchinson applied this term to
a progressive paralysis of the internal ocular muscles, causing loss of pupil-
lary action and the power of accommodation. When the internal and
external muscles are involved the affection is known as total ophthalmo-
plegia, and in a majority of the cases the two conditions are associated.
In some instances the internal form may depend upon disease of the
ciliary ganglion.
AVhile, as a rule, ophthalmoplegia is a chronic process, there is an acute
form associated with haemorrhagic softening of the nuclei of the ocular
muscles. There is usually marked cerebral disturbance. It was to this
form that Wernicke gave the name polio-encephalitis superior.
Treatment of Ocular Palsies. — It is important to ascertain, if
possible, the cause. The forms associated with locomotor ataxia are
obstinate, and resist treatment. Occasionally, however, a palsy, complete
or partial, may pass away spontaneously. The group of cases associated
with chronic degenerative changes, as in progressive paresis and bulbar
paralysis, is little affected by treatment. On the other hand, in syphilitic
cases, mercury and iodide of potassium are indicated and are often bene-
ficial. Arsenic and strychnia, the latter hypodermically, may be employed.
In any case in which the onset is acute, with pain, hot fomentations and
counter-irritation or leeches applied to the temple give relief. The direct
treatment by electricity has been extensively employed, but probably with-
out any special effect. The diplopia may be relieved by the use of prisms,
or it may be necessary to cover the affected eye with an opaque glass.
IV. Fifth Nerve.
Paralysis may result from : (a) Disease of the pons, particularly haem-
orrhage or patches of sclerosis, {h) Injury or disease at the base of the
brain. Fracture rarely involves the nerve ; on the other hand, meningitis,
acute or chronic, and caries of the bone are not uncommon causes, (c) The
branches may be affected as they pass out — the first division by tumors
pressing on the cavernous sinus or by aneurism ; tlie second and third
divisions by growths which invade the spheno-maxillary fossa, {d) Pri-
mary neuritis, which is rare.
Symptoms. — (a) Sensory Portion. — Paralysis of the fifth nerve
causes loss of sensation in the parts supplied, including the half of the
796 DISEASES OF TOE NERVOUS SYSTEM.
face, the corresponding side of the head, the conjunctiva, the mucosa of
the lips, tongue, hard and soft palate, and of the nose of the same side.
The anaesthesia may be preceded by tingling or i)ain. The muscles of the
face are also insensible and the movements may be slower. The sense of
smell is interfered with. There is loss of the sense of taste. There are,
in addition, trophic changes ; the salivary, lachrymal, and buccal secretions
may be lessened, abrasions of the mucous membranes heal slowly, and the
teeth may become loose. The eye inflames, the corneas become cloudy
and may ulcerate. These latter symptoms occur only when the Gasserian
ganglion is aifected, as the nerve itself may be involved for years without
producing ophthalmia. Herpes may develop in the region supplied by
the nerve and is usually associated with much pain. It is most common
in the upper branch of the nerve. The pain which follows the herpes may
be peculiarly enduring, lasting for months or years (Gowers).
{b) Motor Portion. — The inability to use the muscles of mastica-
tion on the affected side is the distinguishing feature of paralysis of this
portion of the nerve. It is recognized by placing the finger on the mas-
seter and temporal muscles, and, when the patient closes the jaw, the
feebleness of their contraction is noted. If paralyzed, the external ptery-
goid cannot move the jaw toward the unaffected side ; and when depressed,
the jaw deviates to the paralyzed side. The motor paralysis of the fifth
nerve is almost invariably a result of involvement of the nerve after it has
left the nucleus. Cases, however, have been associated with cortical
lesions. Hirt concludes, from his case, that the motor centre for the
trigeminus is in the neighborhood of the lower third of the ascending
frontal convolution.
Spasm of the Mtcscles of Mastication. — Trismus, the masticatory spasm
of Romberg, may be tonic or clonic, and is either an associated phenome-
non in general convulsions or, more rarely, an independent affection. In
the tonic form the jaws are kept close together — lock-jaw — or can be
separated only for a short space. The muscles of mastication can be seen
in contraction and felt to be hard and the spasm is often painful. This
tonic contraction is an early symptom in tetanus, and is sometimes seen in
tetany. A form of this tonic spasm occurs in hysteria. Occasionally tris-
mus follows exposure to cold, and is said to be due to reflex irritation from
the teeth, the mouth, or caries of the jaw. It may also be a symptom of
organic disease due to irritation near the motor nucleus of the fifth nerve.
Clonic spasm of the muscles supplied by the fifth occurs in the form of
rapidly repeated contractions, as in " chattering teeth." This is rare apart
from general conditions, though cases are on record, usually in women late
in life, in whom this isolated clonic spasm of the muscles of the jaw has
been found. In another form of clonic spasm sometimes seen in chorea,
there are forcible single contractions. Gowers mentions an instance of its
occurrence as an isolated affection.
{c) Gustatory. — Loss of the sense of taste in the anterior two thirds of
DISEASES OP THE CRANIAL NERVES. 797
the tongue, as a rule, follows paralysis of the fifth nerve. The gustatory-
fibres pass from the chorda tympani to the lingual branch of the fifth.
Disease of the fifth nerve is, however, not always associated witli loss of
taste in the anterior part of the tongue, in which case either the taste
fibres escape, or the disease is within the pons where these fibres are
separate from those of sensation.
The diagnosis of disease of the trifacial nerve is rarely difficult. It
must be remembered that the preliminary pain and hyperaesthesia are
sometimes mistaken for neuralgia. The loss of sensation and the palsy of
the muscles of mastication are readily determined.
Treatment. — When the pain is severe morphia may be required and
local applications are useful. If there is a suspicion of syphilis, appropri-
ate treatment should be given. Faradization is sometimes beneficial.
V. Facial Nerye.
Paralysis {BelVs Palsy). — The portio dura of the seventh pair may
be paralyzed by (1) lesions of the cortex — supranuclear palsy; (2) lesions
of the nucleus itself ; or (3) involvement of the nerve trunk in its tortuous
course within the pons and through the wall of the skull.
I. Supranuclear Paralysis^ due to lesion of the cortex or of the facial
fibres in the corona radiata or internal capsule, is, as a rule, associated
with hemiplegia. It may be caused by tumors, abscess, chronic inflamma-
tion, or softening in the region of the internal capsule. It is distinguished
from the peripheral form by two well-marked characters — the persistence
of the normal electrical excitability of both nerves and muscles and the
absence of involvement of the upper branches of the nerve, so that the or-
bicularis palpebrarum and frontalis muscle are spared. A third difference
is that in this form the voluntary movements are more impaired than the
emotional. There are instances of cortical facial paralysis — monoplegia
facialis — associated with lesions in the centre for the face muscles in the
lower Rolandic region. Isolated paralysis, due to involvement of the nerve
fibres in their path to the nucleus, is uncommon. In the great majority
of cases supranuclear facial paralysis is part of a hemiplegia. Paralysis
is on the same side as that of the arm and leg because the facial mus-
cles bear precisely the same relation to the cortex as the spinal muscles.
The nuclei of origin on either side of the middle line in the medulla are
united by decussating fibres with the cortical centre on the opposite side
(see Fig. 3).
IT. The nuclear paralysis caused by lesions of the nerve centre in the
medulla is not common alone ; but is seen occasionally in tumors, chronic
softening, and haemorrhage. In rare instances of anterior polio-myelitis
the facial nucleus is affected. In diphtheria this centre may also be
involved. The symptoms are practically similar to those of an affection
of the nerve fibre itself — infranuclear paralysis.
798 DISEASES OF THE NERVOUS SYSTEM.
III. Involvement of the Nerve Trunk. — Paralysis may result from:
(a) Involvement of the nerve as it passes through the pons — that is,
between its nucleus in the floor of the fourth ventricle and the point of
emergence in the postero-lateral aspect of the pons. The specially inter-
esting feature in connection with involvement of this part is the production
of what is called alternating or cross paralysis, the face being involved on
the same side as the lesion, and the arm and leg on the opposite side, since
the motor path is involved above the point of decussation in the medulla
(Fig. 3, z). This occurs only when the lesion is in the lower section of the
pons. A lesion in the upper division involves the fibres not of the out-
going nerve on the same side, but of the nerve of the other side, which
has crossed and is ascending to the hemisphere. In this case there would
of course be, as in hemiplegia, paralysis of the face and limbs on the side
opposite to the lesion. The palsy, too, would resemble the cerebral form,
involving only the lower fibres of the facial nerve.
(b) The nerve may be involved at its point of emergence by tumors,
gummata, meningitis, or occasionally may be injured in fracture of the
base.
(c) In passing through the Fallopian canal the nerve may be involved
in disease of the ear, particularly by caries of the bone in otitis media.
This is a common cause in children.
(d) As the nerve emerges from the styloid foramen it is exposed to
injuries and blows which not infrequently cause paralysis. The fibres
may be cut in the removal of tumors in this region, or the paralysis may
be caused by pressure of the forceps in an instrumental delivery.
(e) Exposure to cold is the most common cause of facial paralysis,
inducing a neuritis of the nerve within the Fallopian canal. It is some-
times termed rheumatic neuritis, but there is no evidence that it is spe-
cially associated with the rheumatic poison.
Facial diplegia is a rare condition occasionally found in affections at
the base of the brain, lesions in the pons, simultaneous involvement of the
nerves in ear disease, and in diphtheritic paralysis. Disease of the nuclei
or symmetrical involvement of the cortex might also produce it.
Symptoms. — In the peripheral facial paralysis all the branches of
the nerve are involved. The face on the affected side is immobile and can
neither be moved at will nor participate in any emotional movements.
The skin is smooth and the wrinkles are effaced, a point particularly
noticeable on the forehead of elderly persons. The eye cannot be closed,
the lower lid droops, and the eye waters. On the affected side the angle
of the mouth is lowered, and in drinking the lips are not kept in close
apposition to the glass, so that the liquid is apt to run out. In smiling or
laughing the contrast is most striking, as the affected side does not move,
which gives a curious unequal appearance to the two sides of the face.
The eye cannot be closed and the forehead cannot be wrinkled. On asking
a patient to sliow his upper teeth, the angle of the mouth is not raised. In
DISEASES OF THE CRANIAL NERVES. Y99
all these movements the face is drawn to the sound side by the action of
the muscles. Speaking may be slightly interfered with, owing to the im-
perfection in the formation of the labial sounds. Whistling cannot be
performed. In chewing the food, owing to the paralysis of the buccinator,
particles collect on the affected side. The paralysis of the nasal muscles
is seen on asking the patient to sniff. Owing to the fact that the lips are
drawn to the sound side, the tongue, when protruded, looks as if it were
pushed to the paralyzed side ; but on taking its position from the incisor
teeth, it will be found to be in the middle line. The reflex movements
are lost in this peripheral form. It is usually stated that the palate is
paralyzed on the same side and that the uvula deviates. Both Gowers
and Hughlings Jackson deny the existence of this involvement in the
great majority of cases, and Horsley and Beevor have shown that these
parts are innervated by the accessory nerve to the vagus.
When the nerve is involved within the canal between the genu and
the origin of the chorda tympani, the sense of taste may be lost in the
anterior part of the tongue on the affected side. When the nerve is
damaged outside the skull the sense of taste is unaffected. Hearing is
often impaired in facial paralysis, most commonly by preceding ear dis-
ease. The paralysis of the stapedius muscle may lead to increased sen-
sitiveness to musical notes. Herpes is sometimes associated with facial
paralysis. Pain is not common, but there may be neuralgia about the
ear.
The electrical reacti07is, which are those of a peripheral palsy, have
considerable importance from a prognostic standpoint. Erb's rules are as
follows : If there is no change, either faradic or galvanic, the prognosis
is good and recovery takes place in from fourteen to twenty days. If the
faradic and galvanic excitability of the nerve is only lessened and that of
the muscle increased to the galvanic current and the contraction formula
altered (the contraction sluggish AnC>CC), the outlook is relatively
good and recovery will probably take place in from four to six weeks ; oc-
casionally in from eight to ten. When the reaction of degeneration is
present — that is, if the faradic and galvanic excitability of the nerves and
the faradic excitability of the muscles are lost and the galvanic excita-
bility of the muscle is quantitatively increased and qualitatively changed,
and if the mechanical excitability is altered — the prognosis is relatively
unfavorable and the recovery may not occur for two, six, eight, or even fif-
teen months.
The course of facial paralysis is usually favorable. The onset in the
form following cold is very rapid, developing perhaps within twenty-four
hours, but rarely is the paralysis permanent. On the other hand, in the
paralysis from injury, as by a blow on the mastoid process, the paralysis
may remain. When permanent the muscles are entirely toneless. In some
instances contracture develops as the voluntary power returns, and the natu-
ral folds and the wrinkles on the affected side may be deepened, so that on
800 DISEASES OF THE NERVOUS SYSTEM.
looking at the face one at first may have the impression that the affected
side is the sound one. This is corrected at once on asking the patient to
smile, when it is seen which side of the face has the most active move-
ment.
The diagnosis of facial paralysis is usually easy. The distinction be-
tween peripheral and central is based on facts already mentioned.
Treatment. — In the cases which result from cold and are probably
due to neuritis within the bony canal, hot applications first should be
made ; subsequently the thermo-cautery may be used lightly at intervals
of a day or two over the mastoid process, or small blisters applied.
If the ear is diseased, free discharge for the secretion should be ob-
tained. The continuous current may be employed to keep up the nu-
trition of the muscles. The positive pole should be placed behind the
ear, the negative one along the zygomatic and other muscles. The ap-
plication can be made daily for a quarter of an hour and the patient can
readily be taught to make it himself before the looking-glass. Massage of
the muscles of the face is also useful.
A course of iodide of potassium may be given even when there is no
indication of syphilis.
Spasm. — The spasm may be limited to a few or involve all the muscles
innervated by the facial nerve and may be unilateral or bilateral.
It is known also by the name of mimic spasm or of convulsive tic.
Several different affections are usually considered under the name of facial
or mimic spasm, but we shall here speak only of the simple spasm of the
facial muscles, either primary or following paralysis, and shall not in-
clude the cases of habit spasm in children, or the tic convulsif of the
French.
Gowers recognizes two classes — one in which there is an organic lesion,
and an idiopathic form. It is thought to be due also to reflex causes, such
as the irritation from carious teeth or the presence of intestinal worms.
The disease usually occurs in adults, whereas the habit spasm and the tic
convulsif of the French, often confounded with it, are most common in
children. True mimic spasm occasionally comes on in childhood and per-
sists. In the case of a school-mate, the affection was marked as early as
the eleventh or twelfth year and still continues. When the result of or-
ganic disease there has usually been a lesion of the centre in the cortex, as
in the case reported by Berkeley, or pressure on the nerve at the base of
the brain by aneurism or tumor.
Symptoms. — The spasm may involve only the muscles around the
eye — l^lepliarospasm — in which case there is constant, rapid^ quick action
of the orbicularis palpebrarum, which, in association with photophobia,
may be tonic in character. More commonly the spasm affects the lateral
facial muscles witli those of the eye and there is constant twitching of the
side of the face with partial closure of the eye. The frontalis is rarely in-
DISEASES OF THE CRANIAL NERVES. ' 801
volved. In aggravated cases the depressors of the angle of the mouth, the
levator menti, and the platysma myoides are affected. This spasm is con-
fined to one side of the face in a majority of cases, though it may extend
and become bilateral. It is increased by emotional causes and involuntary
movements of the face. As a rule, it is j^ainless, but there may be tender
points on the course of the fifth nerve, particularly the supraorbital
branch. Tonic spasm of the facial muscle may follow paralysis, and is
said to result occasionally from cold.
The outlook in facial spasm is always dubious. A majority of the
cases persist for years and are incurable.
Treatment. — Sources of irritation should be looked for and re-
moved. AYhen a painful spot is present over the fifth nerve, blistering
or the application of the thermo-cautery may relieve it. Hypodermic
injections of strychnia may be tried, but are of doubtful benefit. Weir
Mitchell recommends the freezing of the cheek for a few minutes daily
or every second day with the spray, and this, in some instances, is bene-
ficial. Often the relief is transient; the cases return, and at every
clinic may be seen half a dozen or more of such patients who have run
the gamut of all measures without material improvement. Operative
interference may be resorted to in severe cases, although not much can
be expected of it.
VI. Auditory Nerve.
This nerve, forming the portio mollis of the seventh pair, enters the
internal auditory meatus, and divides into the cochlear and vestibular
branches. The cortical centre for hearing is in the temporo-sphenoidal
lobe. Primary disease of the auditory nerve in its centre or intracranial
course is uncommon. More frequently the terminal branches are affected
within the labyrinth.
(a) Affection of the Cortical Ceiitre. — In the monkey, experiments
indicate that the first temporal gyri represent the centre for hearing. In
man the cases of disease indicate that it has the same situation, as de-
struction of this gyrus on the left side results in word-deafness, which
may be defined as an inability to understand the meaning of words, though
they may still be heard as sounds. The central fibres of the auditory nerve
between the cortical centre and the nucleus in the fourth ventricle may be
involved and produce deafness. This has resulted from the presence of a
tumor in the corpora quadrigemina, and may be associated with a lesion of
the internal capsule.
{b) Lesions of the nerve at the base of the brain may result from the
pressure of tumors, meningitis (particularly the cerebro-spinal form), hsem-
orrhago, or traumatism. A primary degeneration of the nerve may occur
in locomotor ataxia. Xuclear disease is rare. By far the most interest-
ing form results from epidemic cerebro-spinal meningitis, in which tho
/
802 DISEASES OF THE NERVOUS SYSTEM.
nerve is frequently involved, causing permanent deafness. In young
children the condition results in deaf-mutism.
(c) In a majority of the cases associated with auditory-nerve symptoms
the lesion is in the labyrinth^ either primary or the result of extension of
disease of the middle ear. Three groups of symptoms may be produced —
hyperaesthesia and irritation, diminished function or nervous deafness, and
vertigo.
(1) Ilypercesthesia and Irritation. — This may be due to altered func-
tion of the centre as well as of the nerve ending. True hyperaesthesia —
hyperacusis — is a condition in which sounds, sometimes even those inaudi-
ble to other persons, are heard with great intensity. It occurs in hysteria
and occasionally in cerebral disease. As already mentioned, in paralysis
of the stapedius low notes may be heard with intensity. In dysassthesia,
or dysacusis, ordinary sounds cause an unpleasant sensation, as commonly
happens in connection with headache, when ordinary noises are badly
borne.
Tinnitus aurium is a term employed to designate certain subjectiva
sensations of ringing, roaring, ticking, and whirring noises in the ear. It is
a very common and often a distressing symptom. It is associated with many
forms of ear disease and may result from pressure of wax on the drum. It
is rare in organic disease of the central connections of the nerve. Sudden
intense stimulation of the nerve may cause it. A form not uncommonly
met with in medical practice is that in which the patient hears a continual
hruit in the ear, and the noise has a systolic intensification, usually on
one side. I have twice been consulted by physicians for this condition
under the belief that they had an internal aneurism. It occurs in condi-
tions of anaemia and neurasthenia. Subjective noises in the ear may pre-
cede an epileptic seizure and are sometimes present in migraine. In
whatever form tinnitus exists, though slight and often regarded as trivial,
it occasions great annoyance and often mental distress, and has even driven
patients to suicide.
The diagnosis is readily made ; but it is often extremely difficult to de-
termine upon what condition the tinnitus depends. The relief of con-
stitutional states, such as anaemia, neurasthenia, or gout, may result
in cure. A careful local examination of the ear should always be made.
One of the most worrying forms is the constant clicking, sometimes audi-
ble many feet away from the patient, and due probably to clonic spasm
of the muscles connected with the Eustachian tube or of the levator palati.
The condition may persist for years unchanged, and then disappear sud-
denly. The pulsating forms of tinnitus, in which the sound is like that
of a systolic bruit^ are almost invariably subjective, and nothing is audible
with the stethoscope. It is to be remembered that in children there is a
systolic brain murmur, best heard over the ear, and in some instances is
heard in the adult.
(2) Diminished Function or Nervous Deafness. — In testing for nervous
DISEASES OP THE CRANIAL NERVES. 803
deafness, if the tuning-fork cannot be heard when placed near the meatus,
but the vibrations are audible by placing tlie foot of the tuning-fork against
the temporal bone, the conclusion may be drawn that the deafness is not
due to involvement of the nerve. The vibrations are conveyed through
the temporal bone to the cochlea and vestibule. The watch may be used
for the same purpose, and if the meatus is closed and the watch is heard
better in contact with the mastoid process than when opposite the open
meatus, the deafness is probably not nervous. Practically, disturbance of
the function of the auditory nerve is not a very frequent symptom in
brain-disease, but in all cases the function of the nerve should be carefully
tested
(3) Auditory Vertigo — Meniere's Disease. — In 1861 Meniere, a French
physician, described an affection characterized by noises in the ear, ver-
tigo (which might be associated with loss of consciousness), vomiting, and,
in many cases, progressive loss of hearing. The term is now used to in-
clude all cases of sudden vertigo accompanied by noises in the ear and
deafness. The frequency of vertigo with ear symptoms is striking.
Thus, of 106 cases noted by Gowers, in which there was definite vertigo,
in 94 ear symptoms were present, either tinnitus or deafness or both.
Symptoms. — The attack usually sets in suddenly with a buzzing
noise in the ears and the patient feels as if he was reeling or staggering.
He may feel himself to be reeling, or the objects about him may seem to
be turnings or the phenomena may be combined. The attack is often so
abrupt that the patient falls, though, as a rule, he has time to steady him-
self by grasping some neighboring object. There may be slight but
transient loss of consciousness. In a few minutes, or even less, the ver-
tigo passes off and the patient becomes pale and nauseated, a clammy
sweat breaks out on the face, and vomiting may follow.
The deafness, which is always of a nervous character, may be in only
one ear and is never complete. The tinnitus is described as either a roar-
ing or a throbbing sound. Ocular symptoms may be present ; thus, jerk-
ing of the eyeballs or nystagmus may develop during the attack, or
diplopia.
Labyrinthine vertigo is paroxysmal, coming on at irregular intervals.
Sometimes weeks or months may elapse between the attacks ; in other
cases there may be several attacks in a day. As a rule, the patients have
no affection of the middle ear. The disease rarely occurs in young per-
sons, is most frequent after the fortieth year, and is more common in men
than in women.
The pathology of the disease has been much discussed. There are
two theories concerning its origin — one, that it is due to affection of the
labyrinth itself, which causes a disturbance of equilibrium, such as is
proved by experiment to be associated with lesion of the semicircular
canals ; the other that it is really a trouble involving the centres presiding
over hearing and equilibration.
51
804 DISEASES OF THE NERVOUS SYSTEM.
It has also been held to be a vaso-motor neurosis of the vessels of the
labyrinth. The condition of the labyrinth in these cases is variable.
Acute disease with haemorrhage has been described, or slow progressive
degeneration of the nerves. Giddiness and vomiting may, however, be
produced by irritation in other parts of the ear ; thus, there are instances
in which pressure on the drum or irritation of the external meatus is fol-
lowed by an attack of giddiness and vomiting.
Diagnosis. — The combination of tinnitus with giddiness, with or
without gastric disturbance, is sufficient to establish a diagnosis. There
are other forms of vertigo from which it must be distinguished. The
form known as gastric vertigo, which is associated with dyspepsia and oc-
curs most commonly in persons of middle age, is, as a rule, readily distin-
guished by the absence of tinnitus or evidences of disturbance in the func-
tion of the auditory nerve. This variety of vertigo is much less common
than Trousseau's description would lead us to believe.
The cardio-vascular vertigo, one of the most common forms, occurs in
cases of valvular disease, particularly aortic insufficiency, and as frequently
in arterio-sclerosis.
There is a remarkable form of vertigo described by Gerlier, which is
characterized by attacks of paretic weakness of the extremities, falling of
the eyelids, remarkable depression, but with retention of consciousness.
It attacks only men, and has occurred in epidemic form among laborers in
the canton of Geneva.
Aural vertigo must be carefully distinguished from attacks of petit
mat, or, indeed, of definite epilepsy. It is rare in petit mat to have noises
in the ear or actual giddiness, but in the aura preceding an epileptic attack
the patient may feel giddy. Giddiness and transient loss of consciousness
may be associated with organic disease of the brain, more particularly with
tumor. Vomiting also may be present. A careful investigation of the
symptoms will usually lead to a correct diagnosis.
The outlook in Meniere's disease is uncertain. While many cases re-
cover completely, in others deafness results and the attacks recur at
shorter intervals. In aggravated cases the patient constantly suffers from
vertigo and may even be confined to his bed.
Treatment. — Bromide of potassium, in twenty-grain doses three
times a day, is sometimes beneficial. If there is a history of syphilis,
the iodide should be administered. The salicylates are recommended, and
Charcot advises quinine to cinchonism. In cases in which there is increase
in the arterial tension nitroglycerine may be given, at first in very small
doses, but increasing gradually. It is not specially valuable in Meniere's
disease, but in the cases of giddiness in middle-aged men and women asso-
ciated with arterio-sclerosis it sometimes acts very satisfactorily.
DISEASES OF THE CRANIAL NERVES. 805
yil. Glosso-piiaryngeal Neuve.
This nerve contains botli motor and sensory fibres and is also a nerve
of the special sense of taste to the tongue. It supplies, by its motor
branches, the stylo-pharyngeus and the middle constrictor of the pharynx.
The sensory fibres are distributed to the upper part of the pharynx.
Symptoms. — Of nuclear disturbance we know very little. The
pharyngeal symptoms of bulbar paralysis are probably associated with in-
volvement of the nuclei of this nerve. Lesion of the nerve trunk itself is
rare, but it may be compressed by tumors or involved in meningitis. Dis-
turbance of the sense of taste may result from loss of function of this
nerve, in which case it is chiefly in the posterior part of the tongue and
soft palate. Gowers, however, states that there is no case on record in
which loss of taste in these regions has been produced by disease of the roots
of the glosso-pharyngeal ; whereas, on the other hand, disease of the root
of the fifth nerve may cause loss of taste on the back as well as the front
of the tongue, as if the taste fibres of the glosso-pharyngeal came from the
fifth.
The general disturbances of the sense of taste may here be briefly re-
ferred to. Loss of the sense of taste — ageusia — may be caused by dis-
turbance of the peripheral end organs, as in affections of the mucosa of
the tongue. This is very common in the dry tongue of fever or the furred
tongue of dyspepsia, under which circumstances, as the saying is, every-
thing tastes alike. Strong irritants too, such as pepper, tobacco, or vinegar,
may dull or diminish the sense of taste. Complete loss may be due to in-
volvement of the nerves either in their course or in the centres. Dis-
turbance in the sense of taste is most commonly seen in involvement of
the fifth nerve, and it may be that this nerve alone subserves the function.
Perversion of the sense of taste — parageusis — is rarely found, except as
an hysterical manifestation and in the insane. Increased sensitiveness is
still more rare. There are occasional subjective sensations of taste, occur-
ring as an aura in epilepsy or as part of the hallucinations in the insane.
To test the sense of taste the patient's eyes should be closed and small
quantities of various substances applied. The sensation should be per-
ceived before the tongue is withdrawn. The following are the most suit-
able tests : For bitter, quinine ; for sweetness, a strong solution of sugar or
saccharin ; for acidity, vinegar ; and for the saline test, common salt. One
of the most important tests is the feeble galvanic current, which gives the
well-known metallic taste.
VIII. Pneumogastric Nerve.
The vagus nerve has an important and extensive distribution, supply-
ing the pharynx, larynx, lungs, heart, cesophagus, and stomach. The
nerve may bo involved at its nucleus with the spinal accessory and the
hypoglossal, forming what is known as bulbar paralysis. It may be com-
806 DISEASES OF THE NERVOUS SYSTEM.
pressed by tumors or aneurism, or in the exudation of meningitis, simple
or syphilitic. In its course in the neck the trunk may be involved by
tumors or in wounds. It has been tied in ligature of the carotid, and has
been cut in the removal of deep-seated tumors. The trunk may be at-
tacked by neuritis.
The ajffections of the vagus are best considered in connection with the
distribution of the separate nerves.
(a) Pharyngeal Branches. — In combination with the glosso-pharyngeal
the branches from the vagus form the pharyngeal plexus, from which the
muscles and mucosa of the pharynx are supplied. In paralysis due to
involvement of this either in the nuclei, as in bulbar paralysis, or in the
course of the nerve, as in diphtheritic neuritis, there is difficulty in swal-
lowing and the food is not passed on into the cesophagus. If the nerve on
one side only is involved, the deglutition is not much impaired. In these
cases the particles of food frequently pass into the larynx, and, when the
soft palate is involved, into the posterior nares.
Spasm of the pharynx is always a functional disorder, usually occur-
ring in hysterical and nervous people. Gowers mentions a case of a gen-
tleman who could not eat unless alone, on account of the inability to
swallow in the presence of others from spasm of the pharynx. This spasm
is a well-marked feature in hydrophobia, and I have seen it in a case of
pseudo-hydrophobia.
(b) Laryngeal Branches. — The superior laryngeal nerve supplies the
mucous membrane of the larynx above the cords and the crico- thyroid
muscle. The inferior or recurrent laryngeal curves around the arch of the
aorta on the left side and the subclavian artery on the right, passes along
the trachea and supplies the mucosa below the cords and all the muscles of
the larynx except the crico-thyroid and the epiglottidean. Experiments have
shown that these motor nerves of the pneumogastric are all derived from
the spinal accessory. The remarkable course of the recurrent laryngeal
nerves renders them liable to pressure by tumors within the thorax, par-
ticularly by aneurism. The following are the most important forms of
paralysis :
(1) Bilateral Paralysis of the Abductors.— In this condition, the pos-
terior crico-arytenoids are involved and the glottis is not opened during
inspiration. The cords may be close together in the position of phonation,
and during inspiration may be brought even nearer together by the pressure
of air, so that there is only a narrow chink through which the air whistles
with a noisy stridor. This dangerous form of laryngeal paralysis occurs
occasionally as a result of cold, or may follow a laryngeal catarrh. The
posterior muscles have been found degenerated when the others were
healthy. The condition may be produced by pressure upon both vagi, or
upon both recurrent nerves. As a central affection it occurs in tabes and
bulbar paralysis, but may occur also in hysteria. The characteristic
symptoms are inspiratory stridor with unimpaired phonation. Possibly,
DISEASES OP THE CRANIAL NERVES.
807
as Gowers suggests, many cases of so-called hysterical spasm of the glottis
are in reality abductor paralysis.
(2) Unilateral Abductor Paralysis. — This frequently results from the
pressure of tumors or involvement of one recurrent nerve. Aneurism is
by far the most common cause, though on the right side the nerve may
be involved in thickening of the pleura. The symptoms are hoarseness
or roughness of the voice, such as is so common in aneurism. Dyspnoea
is not often present. The cord on the affected side does not move in in-
spiration. Subsequently the adductors may also become involved, in which
case the phonation is still more impaired.
(3) Adductor Paralysis. — This results from involvement of the lateral
crico-arytenoid and the arytenoid muscle itself. It is common in hysteria,
particularly of women, and causes the hysterical aphonia, which may
come on suddenly. It may result from catarrh of the larynx or from
overuse of the voice. In larjnagoscopic examination it is seen, on attempt
at phonation, that there is no power to bring the cords together. In this
connection the following table from Gowers work will be found valuable to
the student :
Symptoms.
No voice ; no cough ;
stridor only on deep in-
spiration.
Voice low pitched
and hoarse ; no cough ;
stridor absent or slight
on deep breathing.
Voice little changed ;
cough normal ; inspira-
tion difficult and long,
with loud stridor.
Symptoms incon-
c^lusive ; little affection
of voice or cough.
No voice ; perfect
cough ; no stridor or
dyspnoea.
Signs.
Both cords moder-
ately abducted and mo-
tionless.
One cord moder-
ately abducted and mo-
tionless, the other mov-
ing freely, and even
beyond the middle line
in phonation.
Both cords near to-
gether, and during in-
spiration not separated,
but even drawn nearer
together.
One cord near the
middle line not moving
during inspiration, the
other normal.
Cords normal in po-
sition and moving nor-
mally in respiration,
but not brought to-
gether on an attempt
at phonation.
Lesion.
Total bilateral palsy.
Total unilateral palsy
Total abductor palsy.
Unilateral abductor
palsy.
Adductor palsy.
808 DISEASES OF THE NERVOUS SYSTEM.
Spasm of the Muscles of the Larynx. — In this the adductor muscles
are involved. It is not an uncommon affection in children, and has al-
ready been referred to as laryngismus stridulus. Paroxysmal attacks of
laryngeal spasm are rare in the adult, but cases are described in which the
patient, usually a young girl, wakes at night in an attack of intense dysp-
noea, which may persist long enough to produce cyanosis. Liveing states
that they may replace attacks of migraine. They occur in a characteristic
form in locomotor ataxia, forming the so-called laryngeal crises. There is
a condition known as spastic aphonia, in which, when the patient attempts
to speak, phonation is completely prevented by a spasm.
Disturbance of the sensory nerves of the larynx is rare.
Ancesthesia may occur in bulbar paralysis and in diphtheritic neuritis —
a serious condition, as portions of food may enter the windpipe. It is
usually associated with dysphagia and is sometimes present in hysteria.
Hyi:)er8esthesia of the larynx is rare.
(6') Cardiac Branches. — The cardiac plexus is formed by the union of
branches of the vagi and of the sympathetic nerves. The vagus fibres sub-
serve motor, sensory, and probably trophic functions.
(1) Motor. — The fibres which inhibit, control, and regulate the cardiac
action pass in the vagi. Irritation may produce slowing of the action. Czer-
mak could slow or even arrest the heart's action for a few beats by pressing a
small tumor in his neck against one pneumogastric nerve, and it is said
that the same can be produced by forcible bilateral pressure on the ca-
rotid canal. There are instances in which persons appear to have had vol-
untary control over the action of the heart. The most remarkable in-
stance was that of Colonel Townsend, who could slow the action of the
heart at will. Eetardation of the heart's action has also followed acci-
dental ligature of one vagus. Irritation at the nuclei may also be accom-
panied by extreme slowness. The condition of brachycardia may be asso-
ciated with a neurosis of this nerve. On the other hand, when there is
complete paralysis of the vagi, the inhibitory action may be abolished
and the acceleratory influences have full sway. The heart's action is then
greatly increased. This is seen in some instances of diptheritic neuritis
and in involvement of the nerve by tumors, or its accidental removal or
ligature. Complete loss of function of one vagus may, however, not be
followed by any symptoms.
(2) Sensory symptoms on the part of the cardiac branches are very
varied, formally, tlie heart's action proceeds regularly without the par-
ticipation of consciousness, but the unpleasant feelings and sensations of
palpitation and pain are conveyed to tlie brain through this nerve. How
far the fibres of tlie pneumogastric are involved in angina it is impossible
to say. Tlie various disturbances of sensation are described under the
cardiac neuroses.
{(1) Pulmonary Branches. — We know very little of tlie pulmonary
branches of the vagi. The motor fibres are stated to control the action of
DISEASES OF THE CRANIAL NERVES. 809
the bronchial muscles, and it has long been held that asthma may be a neu-
rosis of these fibres. The various alterations in the respiratory rhythm are
probably due more to changes in the centre than in the nerves them-
selves.
(e) Gastric and (Esophageal Branches. — The muscular movements of
these parts are presided over by the vagi and vomiting is induced through
them, usually reflexly, but also by direct irritation, as in meningitis. Spasm
of the oesophagus generally occurs with other nervous phenomena. Gas-
tralgia may sometimes be due to cramp of the stomach, but is more com-
monly a sensory disturbance of this nerve, due to direct irritation of the
peripheral ends, or is a neuralgia of the terminal fibres. Hunger is said
to be a sensation aroused by the pneumogastric, and some forms of nervous
dyspepsia probably depend upon disturbed function of this nerve. The
severe gastric crises which occur in locomotor ataxia are due to central
irritation of the nuclei. Some describe exophthalmic goitre under lesions
of the vagi.
IX. Spinal Accessory Nerve.
Paralysis. — The smaller or internal part of this nerve joins the vagus
and is distributed through it to the laryngeal muscles. The larger external
part is distributed to the sterno-mastoid and trapezius muscles.
The nuclei of the nerve, particularly of the accessory part, may be in-
volved in bulbar paralysis. The nuclei of the external portion, situated
as they are in the cervical cord, may be attacked in progressive degenera-
tion of the motor nuclei of the cord. The nerve may be involved in
the exudation of meningitis, or be compressed by tumors, or in caries.
The symjytojns of paralysis of the accessory portion which joins the vagus
have already been given in the account of the palsy of the laryngeal
branches of the pneumogastric. Disease or compression of the external
portion is followed by paralysis of the sterno-mastoid and of the trapezius
on the same side. In paralysis of one sterno-mastoid, the patient rotates
the head with difficulty to the opposite side, but there is no torticollis,
though in some cases the head is held obliquely. As the trapezius is
supplied in part from the cervical nerves, it is not completely paralyzed,
but the portion which passes from the occipital bone to the acromion is
functionless. The paralysis of the muscle is well seen when the patient
draws a deep breath or shrugs the shoulders. The middle portion of the
trapezius is also weakened, the shoulder droops a little, and the angle of
the scaj)ula is rotated inward by the action of the rhomboids and the levator
anguli scapula}. Elevation of the arm is impaired, for the trapezius does
not fix the scapula as a point from which the deltoid can work.
In progressive muscular atrophy we sometimes see bilateral paralysis
of these muscles. Thus, if the sterno-mastoids are affected, the head
tends to fall back ; when the trapezii are involved, it falls forward, a
characteristic attitude of the head in many cases of progressive muscular
810 DISEASES OF THE NERVOUS SYSTEM.
atrophy. Gowers suggests that lesions of the accessory in difficult labor
may account for those cases in which during the first year of life the
child has great difficulty in holding up the head. In children this droop-
ing of the head is an important symptom in cervical meningitis, the
result of caries.
The treatment of the condition depends much upon the cause. In the
central nuclear atrophy but little can be done. In paralysis from pressure
the symptoms may gradually be relieved. The paralyzed muscles should
be stimulated by electricity and massage.
Accessory Spasm. — {Torticollis; Wryneck.) — The forms of spasm
affecting the cervical muscles are best considered here, as the muscles
supplied by the accessory are chiefly, though not solely, responsible for the
condition. The following forms may be described in this section :
{a) Congenital Torticollis. — This condition, also known as fixed torti-
collis, depends upon the shortening and atrophy of the sterno-mastoid on
one side. It occurs in children and may not be noticed for several years
on account of the shortness of the neck, the parents often alleging that it
has only recently come on. It affects the right side almost exclusively.
A remarkable circumstance in connection with it is the existence of facial
asymmetry noted by Wilks, which appears to be an essential part of this
congenital form. It occurred in six cases reported by Golding-Bird. In a
case recently under my observation, the wryneck was not noticed until
her tenth year. The muscle was divided and she seemed quite well ; but
as she developed the asymmetry of the face became very striking. In con-
genital wryneck the sterno-mastoid is shortened, hard and firm, and in a
condition of more or less advanced atrophy. This must be distinguished
from the local thickening in the sterno-mastoid due to rupture, which may
occur at the time of birth and produce an induration or muscle callus.
Although the sterno-mastoid is almost always affected, there are rare cases
in which the fibrous atrophy affects the trapezius. This form of wryneck
in itself is unimportant, since it is readily relieved by tenotomy, but
Golding-Bird states that the facial asymmetry persists, or indeed may, as
shown by photographs in my case, become more evident. With reference
to the pathology of the affection, Golding-Bird concludes that the facial
asymmetry and the torticollis are integral parts of one affection which
has a central origin and is the counterpart in the head and neck of infan-
tile paralysis with talipes in the foot.
(/;) Sjiasmodic Wryneck. — Two varieties of this spasm occur, the tonic
and tlie clonic, which may alternate in the same case ; or, as is most
common, they are separate and remain so from the outset. The dis-
ease is most frequent in adults and, according to Gowers, most common in
females. In this country it is certainly more frequent in males. Of the
eight or ten cases which came under my observation in Montreal and
Philadelphia, all were males. In females it may be an hysterical manifes-
tation. There may be a marked neurotic family history, but it is usually
DISEASES OF THE CllANIAL NKRVES. 811
impossible to fix upon any definite etiological factor. Some cases have
followed cold ; others a blow.
The symptoms are well defined. In the tonic form the contracted
sterno-mastoid draws the occiput toward the shoulder of the affected side ;
the chin is raised, and the face rotated to the other shoulder. The sterno-
mastoid may be affected alone or in association with the trapezius. When
the latter is implicated the head is depressed still more toward the same
side. In long-standing cases these muscles are prominent and very rigid.
There may be some curvature of the spine, the convexity of which is toward
the sound side. The cases in which the spasm is clonic are much more
distressing and serious. The spasm is rarely limited to a single muscle.
The sterno-mastoid is almost always involved and rotates the head so as to
approximate the mastoid process to the inner end of the clavicle, turning
the face to the opposite side and raising the chin. When with this the
trapezius is affected, the depression of the head toward the same side is
more marked. The head is drawn somewhat backward ; the shoulder,
too, is raised by its action. According to Gowers, the splenius is associated
with the sterno-mastoid about half as frequently as the trapezius. Its ac-
tion is to incline the head and rotate it slightly toward the same side.
Other muscles may be involved, such as the scalenus and platysma myoides ;
and in rare cases the head may be rotated by the deep cervical muscles,
the rectus and obliquus. There are cases in which the spasm is bilateral,
causing a backward movement — the retro-collic spasm. This may be
either tonic or clonic, and in extreme cases the face is horizontal and looks
upward.
These clonic contractions may come on without warning, or be pre-
ceded for a time by irregular pains or stiffness of the neck. The jerking
movements recur every few moments, and it is impossible to keep the head
still for more than a minute or two. In time the muscles undergo hyper-
trophy and may be distinctly larger on one side than the other. In some
cases the pain is considerable ; in others there is simply a feeling of fatigue.
The spasms cease during sleep. Emotion, excitement, and fatigue increase
them. The spasm may extend from the muscles of the neck and involve
those of the face or of the arms.
The disease varies much in its course. Cases occasionally get well, but
the great majority of them persist, and, even if temporarily relieved, the
disease frequently recurs. The affection is usually regarded as a functional
neurosis, but it is possibly due to disturbance of the cortical centres pre-
siding over the muscles.
Treatment. — Temporary relief is sometimes obtained; a perma-
nent cure is exceptional. Various drugs have been used, but rarely
with benefit. Occasionally, large doses of bromide will lessen the in-
tensity of tlio spasm. Morphia, subcutaneously, has been successful in
some reported cases, but there is the great danger of establishing the
morphia habit. Galvanism may be tried. Counter-irritation is probably
812 DISEASES OF THE NERVOUS SYSTEM.
useless. Fixation of the head mechanically can rarely be borne by the
patient. These obstinate cases fall ultimately into the hands of the sur-
geon, and the operations of stretching, division, and excision of the acces-
sory nerve and division of the muscles have been tried. The latter does
not check the spasm, and may aggravate the symptoms. Temporary
relief may follow, but, as a rule, the condition returns. In the cases of
spasm of the deep-seated muscles. Keen has devised an operation for their
section.
(6') The nodding spasm of children may here be mentioned as involv-
ing chiefly the muscles innervated by the accessory nerve. It may be a
simple trick, a form of habit spasm, or a phenomenon of ei)ilepsy (E. nu-
tans), in which case it is associated with transient loss of consciousness.
A similar nodding spasm may occur in older children. In women it some-
times occurs as an hysterical manifestation, commonly as part of the so-
called salaam convulsion.
X. Hypoglossal Nerve.
This is the motor nerve of the tongue and for most of the muscles at-
tached to the hyoid bone. Its cortical centre is probably the lower part of
the ascending frontal gyrus.
Paralysis. — (1) Central Lesion. — The tongue is often paralyzed in
hemiplegia, and the paralysis may result from a lesion of the cortex itself,
or of the fibres as they pass to the medulla. It does not occur alone and
will be considered with hemiplegia. There is this difference, however, be-
tween the cortical and other forms, that the muscles on both sides of the
tongue may be more or less affected but do not waste, nor are their elec-
trical reactions disturbed.
(2) Nuclear and infra-nuclear lesions of the hypoglossal result from
slow progressive degeneration, as in bulbar paralysis or in locomotor
ataxia, and occasionally there is acute softening from obstruction of the
vessels. Trauma and lead poisoning have also been assigned as causes.
The fibres may be damaged by a tumor, and at the base by meningitis ;
or the nerve is sometimes involved in its foramen by disease of the skull.
The nuclei of both nerves are usually affected together, but may be at-
tacked separately. As a result, there is loss of function in the nerve fibres
and the tongue undergoes atrophy on the affected side. It is protruded
toward the paralyzed side and may show fibrillary twitching.
The symptoms of involvement of one liypoglossal, either at its centre
or in its course, are those of unilateral paralysis and atrophy of the tongue.
When protruded, it is pushed toward the affected side, and there are fi-
brillary twitch ings. The atrophy is usually marked and the mucous mem-
brane on the affected side is thrown into folds. Articulation is not much
impaired in the unilateral affection. When the disease is bilateral, the
tongue lies almost motionless in tlie floor of the mouth ; it is atrophied.
DISEASES OP THE SPINAL NERVES. 813
and cannot be protruded. Speech and mastication are extremely difficult
and deglutition may be impaired. If the seat of the disease is above the
nuclei, there may be little or no wasting. The condition is seen in pro-
gressive bulbar paralysis and occasionally in progressive muscular atrophy.
The diagnosis is readily made and the situation of the lesion can
usually be determined, since when supra-nuclear there is associated hemi-
plegia and no wasting of the muscles of the tongue. Nuclear disease is
only occasionally unilateral ; most commonly bilateral and part of a bulbar
paralysis. It should be borne in mind that the fibres of the hypoglossal
may be involved within the medulla after leaving their nuclei. In such
a case there may be paralysis of the tongue on one side and paralysis of
the limbs on the opposite side, and the tongue, when protruded, is pushed
toward the sound side.
Spasm. — This rare affection may be unilateral or bilateral. It is most
frequently a part of some other convulsive disorder, such as epilepsy,
chorea, or spasm of the facial muscles. In some cases of stuttering, spasm
of the tongue precedes the explosive utterance of the words. It may oc-
cur in hysteria, and is said to follow reflex irritation in the fifth nerve.
The most remarkable cases are those of paroxysmal clonic spasm, in which
the tongue is rapidly thrust in and out, as many as forty or fifty times a
minute. In the case reported by Gowers the attacks occurred during
sleep and continued for a year and a half. The spasm is usually bilateral.
Wendt has reported a case in which it was unilateral. The prognosis is
usually good.
IV. DISEASES OF THE SPINAL NERVES.
Cervical Plexus.
(1) Occipitocervical Neuralgia. — This involves the nerve territory
supplied by the second, the occipitalis major and minor, and the auricu-
laris magnus nerves. The pains are chiefly in the back of the head and
neck and in the ear. The condition may follow cold and is sometimes
associated with stiffness of the neck or torticollis. Unless connected with
disease of the bones or due to pressure of tumors, the outlook is usually
good. There are tender points midway between the mastoid process and
the spine and just above the parietal eminence, and between the sterno-
mastoid and the trapezius. The affection may be due to direct pressure, in
persons who carry very heavy loads on the neck.
(2) Affections of the Phrenic Nerve. — Paralysis may follow a lesion in
the anterior horns at the level of the third and fourth cervical nerves, or
may be due to compression of the nerve by tumors or aneurism. More
rarely paralysis results from neuritis.
It may be part of a diphtheritic or lead palsy and is usually bilateral.
814 DISEASES OF THE NERVOUS SYSTEM.
Wlien the diaphragm is paralyzed respiration is carried on by the inter-
costal and accessory muscles. AVhen the patient is quiet and at rest
little may be noticed, but the abdomen retracts in inspiration and is forced
out in expiration. On exertion or even on attempting to move there may
be dyspnoea. If the paralysis sets in suddenly there may be dypnoea
and lividity, which is usually temporary (W. Pasteur). Intercurrent at-
tacks of bronchitis seriously aggravate the condition. Difficulty in cough-
ing, owing to the impossibility of drawing a full breath, adds greatly to
the danger of this complication, as the mucus accumulates in the tubes.
When the phrenic nerve is paralyzed on one side the paralysis may be
scarcely noticeable, but careful inspection shows that the descent of the
diaphragm is much less on the affected side.
The diagnosis of paralysis is not always easy, particularly in women,
who habitually use this muscle less than men, and in whom the dia-
phragmatic breathing is less conspicuous. Immobility of the diaphragm
is not uncommon, particularly in diaphragmatic pleurisy, in large effu-
sions, and in extensive emphysema. The muscle itself may be degener-
ated and its power impaired.
Owing to the lessened action of the diaphragm, there is a tendency to
accumulation of blood at the bases of the lungs, and there may be im-
paired resonance and signs of oedema. As a rule, however, the paralysis
is not confined to this muscle, but is part of a general neuritis or an an-
terior polio-myelitis, and there are other symptoms of value in determin-
ing its presence. The outlook is usually serious. Pasteur states that of
fifteen cases following diphtheria, only eight recovered. The treatment
is that of the neuritis or polio-myelitis with which it is associated.
Brachial Plexus.
(1) Combined Paralysis. — The plexus may be involved in the supra-
clavicular region by compression of the nerve trunks as they leave the
spine, or by tumors and other morbid processes in the neck. Below the
clavicle lesions are more common and result from injuries following dislo-
cation or fracture, sometimes from neuritis. The most common cause
of lesion of the brachial plexus is luxation of the humerus, particularly
the subcoracoid form. If the dislocation is quickly reduced the symp-
toms are quite transient, and disappear in a few days. In severe cases all
the branches of the plexus, or only one or two, may be involved. The
most serious cases are those in which the dislocation is undetected or unre-
duced for some time, when the prolonged pressure on the nerves may cause
complete and permanent paralysis of the arm. The muscles waste, the
reaction of degeneration is present, and trophic changes in the skin are
apt to occur. The medico-legal bearings of these cases are important, and
may be thus briefly summarized : Direct injury, as by a fall or blow on the
shoulder, resulting in great bruising of the nerves without dislocation, is
DISEASES OF THE SPINAL NERVES. 815
occasionally followed by complete paralysis of the arm. A dislocation may
be set immediately and yet the lesion of the brachial plexus may be such
as to cause permanent paralysis of the nerves. The dislocation may be
reduced and the joint in subsequent movements slips out again. It has
happened that by the time the surgeon sees the patient again, the damage
has become irreparable.
Injuries and blows on the neck may cause partial paralysis of the arm,
involving the deltoid, supraspinatus, infraspinatus, biceps, brachialis an-
ticus, and the supinatus. The injury may occur to the child during de-
livery.
A primary neuritis of the brachial plexus is rare. More commonly
the process is an ascending neuritis from a lesion of a peripheral branch,
involving first the radial or ulnar nerves, and spreading upward to the
plexus, producing gradually complete loss of power in the arm.
(2) Lesions of Individual Nerves of the Plexus. — (a) Long Thoracic
Nerve {Serratus Palsy). — This occurs chiefly in men. The nerve is injured
in the posterior triangle of the neck, usually by direct pressure in the
carrying of loads ; cold may cause neuritis. It may be involved also in
progressive muscular atrophy and in polio-myelitis anterior. When par-
alyzed the scapula on the affected side looks winged, which results from
the projection of the angle and posterior border. This is particularly
noticeable when the arm is moved forward, when the serratus no longer
holds the scapula against the thorax. It is a well-defined and readily
recognized form of paralysis. The onset is associated with, sometimes
preceded by, neuralgic pains. The course is dubious, and many months
may elapse before there is any improvement.
{h) Circumflex Nerve. — This supplies the deltoid and the teres minor.
The nerve is apt to be involved in injuries, in dislocations, bruising by a
crutch, or sometimes by extension of inflammation from the joint. Occa-
sionally the paralysis arises from a pressure neuritis during an illness. As
a consequence of loss of power in the deltoid, the arm cannot be raised.
The wasting is usually marked and changes the shape of the shoulder.
Sensation may also be impaired in the skin over the muscle. The joint
may be relaxed and there may be a distinct space between the head of the
humerus and the acromion. In other instances the ligaments are thick-
ened, and a condition not unlike ankylosis may be produced, which is
readily distinguished on moving the arm.
{c) Musculo- spiral Paralysis ; Radial Paralysis. — This is one of the
most common of peripheral palsies, and results from the exposed position
of the musculo-spiral nerve. It is often bruised in the use of the crutch,
by injuries of the arm, blows, or fractures. It is frequently injured when
a person falls asleep with the arm over the back of a chair, or by pressure
of the body upon the arm when a person is sleeping on a bench or on the
ground. It may be paralyzed by sudden violent contraction of the triceps.
It is sometimes involved in a neuritis from cold, but this is uncommon in
816 DISEASES OF THE NERVOUS SYSTEM.
comparison with other causes. In the subcutaneous injection of ether the
nerve may be accidentally struck and temporarily paralyzed. The paraly-
sis of lead poisoning is the result of involvement of certain branches of
this nerve.
A lesion when high up involves the triceps, the brachialis anticus, and
the supinator longus, as well as the extensors of the wrists and fingers.
Naturally, in lesions just above the elbow the arm muscles and the supina-
tor longus are spared. The most characteristic feature of the paralysis is
the wrist-drop and the inability to extend the first phalanges of the fingers
and thumb. In the pressure palsies the supinators are usually involved
and the movements of supination cannot be accomplished. The sensa-
tions may be impaired, or there may be marked tingling, but the loss of
sensation is rarely so pronounced as that of motion.
The affection is readily recognized, but it is sometimes difficult to say
upon what it depends. The sleep and pressure palsies are, as a rule, uni-
lateral and involve the supinator longus. The paralysis from lead is bi-
lateral and the supinators are unaffected. Bilateral wrist-drop is a very
common symptom in many forms of multiple neuritis, particularly the
alcoholic ; but the mode of onset and the involvement of the legs and
arms are features which make the diagnosis easy. The duration and
course of the musculo-spiral paralysis are very variable. The pressure pal-
sies may disappear in a few days. Recovery is the rule, even when the
affection lasts for many weeks. The electrical examination is of impor-
tance in the prognosis, and the rules laid down under paralysis of the facial
nerve hold good here.
The treatment is that of neuritis.
(d) Ulnar Nerve. — The motor branches supply the ulnar halves of the
deep flexor of the fingers, the muscles of the little finger, the interossei,
the adductor, the inner head of the short flexor of the thumb, and the
ulnar flexor of the wrist. The sensory branches supply the ulnar side of
the hand — two and a half fingers on the back, and one and a half finger
on the front. Paralysis may result from pressure, usually at the elbow-
joint, although the nerve is here protected. Possibly the neuritis in the
ulnar nerve in some cases of acute illness may be due to this cause. Gowers
mentions the case of a lady who twice had ulnar neuritis after confinement.
Owing to paralysis of the ulnar flexor of the wrist, the hand moves toward
the radial side; adduction of the thumb is impossible; the first phalanges
cannot be flexed, and the others cannot be extended. In long-standing
cases the first phalanges are overextended and the others strongly flexed,
producing the claw-hand ; but this is not so marked as in the progressive
muscular atrophy. The loss of sensation corresponds to the sensory dis-
tribution just mentioned.
(e) Median Nerve. — This supplies the flexors of the fingers except the
ulnar half of the deep flexors, the abductor and the flexors of the thumb,
the two radial lumbricales, the pronators, and the radial flexors of the wrist.
DISEASES OP THE SPINAL NERVES. 817
The sensory fibres supply tlie radial side of the palm and the front of the
thumb, the first two fingers and half the third finger, and the dorsal sur-
faces of the same three fingers.
This nerve is seldom involved alone. Paralysis results from injury
and occasionally from neuritis. The signs are inability to prouate the
forearm beyond the mid-position. The wrist can only be flexed toward
the ulnar side; the thumb cannot be opposed to the tip of the finger.
The second phalanges cannot be flexed on the first ; the distal phalanges of
the first and second fingers cannot be flexed ; but in the third and fourth
fingers this action can be performed by the ulnar half of the flexor pro-
fundus. The loss of sensation is in the region corresponding to the sensory
distribution already mentioned. The w^asting of the thumb muscles, which
is usually marked in this paralysis, gives to it a characteristic appearance.
Lumbar a^^d Sacral Plexuses.
The lumbar plexus is sometimes involved in growths of the lymph
glands, in psoas abscess, and in disease of the bones of the vertebrae. Of
its branches the obturator nerve is occasionally injured during parturi-
tion When paralyzed the power is lost over the adductors of the thigh
and one leg cannot be crossed over the other. Outward rotation is also
disturbed. The anterior crural nerve is sometimes involved in wounds
or in dislocation of the hip-joint, less commonly during parturition, and
sometimes by disease of the bones and in psoas abscess. The special
symptoms of affection of this nerve are paralysis of the extensors of the
knee with wasting of the muscles, anaesthesia of the antero-lateral parts of
thigh and of the inner side of the leg to the big toe. This nerve is some-
times involved early in growths about the spine, and there may be pain in
its area of distribution. Loss of the power of abducting the thigh results
from paralysis of the gluteal nerve^ which is distributed to the gluteus,
medius, and minimus muscles.
The sacral plexus is frequently involved in tumors and inflammations
within the pelvis and may be injured during parturition. ;N"euritis is
common, usually an extension from the sciatic nerve.
Of the branches, the sciatic nerve^ when injured at or near the notch,
causes paralysis of the flexors of the legs and the muscles below the knee,
but injury below the middle of the thigh involves only the latter muscles.
There is also anaesthesia of the outer half of the leg, the sole, and the greater
portion of the dorsum of the foot. Wasting of the muscles frequently
follows, and there may be trophic disturbances. In paralysis of one sciatic
the leg is fixed at the knee by the action of the quadriceps extensors and
the patient is able to walk.
Paralysis of the small sciatic nerve is rarely seen. The gluteus maximus
is involved and there may be difficulty in rising from a seat. There is a
strip of anaesthesia along the back of the middle third of the thigh.
818 DISEASES OF THE NERVOUS SYSTEM.
Exter7ial Popliteal Nerve. — Paralysis involves the peronaei, the long ex-
tensors of the toes, tibialis anticus, and the extensor brevis digitorum.
The ankle cannot be flexed, resulting in a condition known as foot-drop,
and as the toes cannot be raised the whole leg must be lifted, producing
the characteristic steppage gait seen in so many forms of peripheral neu-
ritis. In long-standing cases the foot is permanently extended and there
is wasting of the anterior tibial and peroneal muscles. The loss of sensa-
tion is in the outer half of the front of the leg and on the dorsum of
the foot.
Internal Popliteal Nerve. — When paralyzed plantar flexion of the foot
and flexion of the toes are impossible. The foot cannot be adducted, nor
can the patient rise on tiptoe. In long-standing cases talipes calcaneus
follows and the toes assume a claw-like position from secondary contract-
ure, due to overextension of the proximal and flexion of the second and
third phalanges.
Sciatica.
This is, as a rule, a neuritis either of the sciatic nerve or of its cords
of origin. It may in some instances be a functional neurosis or neuralgia.
It occurs most commonly in adult males. A history of rheumatism or
of gout is present in many cases. Exposure to cold, particularly after
heavy muscular exertion, or a severe wetting are not uncommon causes.
Within the pelvis the nerves may be compressed by large ovarian or
uterine tumors, by lymphadenomata, by the foetal head during labor, and
occasionally lesions of the hip-joint induce a secondary sciatica. The con-
dition of the nerve has been examined in a few cases, and it has often
been seen in the operation of stretching. It is, as a rule, swollen, red-
dened, and in a condition of interstitial neuritis. The affection may be
most intense at the sciatic notch or in the nerve about the middle of the
thigh.
Of the symptoms., pain is the most constant and troublesome. The
onset may be severe, with slight pyrexia, but, as a rule, it is gradual, and
for a time there is only slight pain in the back of the thigh, particularly
in certain positions or after exertion. Soon the pain becomes more
intense, and instead of being limited to the upper portion of the nerve,
extends down the thigh, reaching the foot and radiating over the entire
distribution of the nerve. The patient can often point out the most sen-
sitive spots, usually at the notch or in the middle of the thigh ; and on
pressure these are exquisitely painful. The pain is described as gnawing or
burning, and is usually constant, but in some instances is paroxysmal, and
often worse at night. On walking it may be very great; the knee is bent
and the patient treads on the toes, so as to relieve the tension on the nerve.
In protracted cases there is wasting of the muscles, but the reaction of
degeneration can seldom be obtained. In these chronic cases cramp may
occur and fibrillar contractions. Herpes may develop, but this is un-
DISEASES OF THE SPINAL NERVES. 819
usual. In rare instances the neuritis ascends and involves tlie S2)inal
cord.
The duration and course are extremely variable. As a rule it is an
obstinate affection, lasting for months, or even, with slight remissions, for
years. Kelapses are not uncommon, and the disease may be relieved in
one nerve only to appear in the other. In the severer forms the patient is
bedridden, and such cases prove among the most distressing and trying
which the physician is called upon to treat.
In the diag?iosis it is important, in the first place, to determine whether
the disease is primary, or secondary to some affection of the pelvis or of
the spinal cord. A careful rectal examination should be made, and, in
women, pelvic tumor should be excluded. Lumbago may be confounded
with it. Affections of the hip-joint are easily distinguished by the
absence of tenderness in the course of the nerve and the sense of pain
on movement of the hip- joint or on pressure in the region of the tro-
chanter. There are instances of sacro-iliac disease in which the patient
complains of pain in the upper part of the thigh, which may sometimes
radiate ; but careful examination will readily distinguish between the
affections. Pressure on the nerve trunks of the cauda equina, as a rule,
causes bilateral pain and disturbances of sensation, and, as double sciatica
is rare, these circumstances always suggest lesion of the nerve roots. Be-
tween the severe lightning pains of tabes and sciatica the differences are
usually well defined.
Treatment. — The pelvic organs should be carefully and systemati-
cally examined. Constitutional conditions, such as rheumatism and gout,
should receive appropriate treatment. In a few cases with pronounced
rheumatic history, which come on acutely with fever, the salic3dates seem
to do good. In other instances they are quite useless. If there is a sus-
picion of S}^3hilis the iodide of potassium should be employed, and in
gouty cases salines.
Kest in bed with fixation of the limb by means of a long splint is a
most valuable method of treatment in many cases, one upon which Weir
Mitchell has specially insisted. I have known it to relieve, and in some
instances to cure, obstinate and protracted cases which had resisted all
other treatment. Hydrotherapy is sometimes satisfactory, particularly the
warm baths or the mud baths. Many cases are relieved by a prolonged
residence at one of the thermal springs.
Antipyrin, antifebrin, and quinine, are of doubtful benefit.
Local applications are more beneficial. The hot iron or the thermo-
cautery or blisters relieve the pain temporarily. Deep injections into the
nerves give great relief and may be necessary for the pain. It is best to
use cocaine at first, in doses of from an eighth to a quarter of a grain. If
the pain is unbearable morphia may be used, but it is a dangerous remedy
in sciatica and should be withheld as long as possible. The disease is so
protracted, so liable to relapse, and the patient's morale so undermined by
52
820 DISEASES OF THE NERVOUS SYSTEM.
the constant worry and the sleepless nights, that the danger of contract-
ing the morphia habit is very great. On no consideration should the
patient be permitted to use the hypodermic needle himself. It is remark-
able how promptly, in some cases, the injection of distilled water into the
nerve will relieve the pain. Acupuncture may also be tried ; the needles
should be thrust deeply into the most painful spot for a distance of about
two inches, and left for from fifteen to twenty minutes. The injection of
chloroform into the nerve has also been recommended.
Electricity is an uncertain remedy. Sometimes it gives prompt relief ;
in other cases it may be used for weeks without the slightest benefit. It
is most serviceable in the chronic cases in which there is wasting of the
legs, and should be combined with massage. The galvanic current should
be used ; a flat electrode should be placed over the sciatic notch, and a
smaller one used along the course of the nerve and its branches. In very
obstinate cases nerve-stretching may be employed. It is sometimes suc-
cessful ; but in other instances the condition recurs and is as bad as ever.
II. DISEASES OF THE SPINAL COED.
I. AFFECTIONS OF THE MENINGES.
Diseases of the Duka Mater.
Pachymeningitis, — The dura mater of the cord is separated by a loose
connective tissue from the bony canal in which it lies, and an inflamma-
tion may involve either its outer or its inner aspect ; hence the division
into pachymeningitis externa and interna.
(a) P achy meningitis Externa. — This is invariably a secondary inflam-
mation and is occasionally met with in an acute form in caries or in syphi-
litic affections of the bone. Abscess may penetrate the spinal canal or
the inflammation may even extend to the peridural tissue in long-standing
decubitus. The symptoms are usually those of a compression myelitis.
The chronic form of external pachymeningitis, also a secondary affec-
tion, is much more common. It is a constant accompaniment of tuber-
culous disease of the spine and plays a very important part in the produc-
tion of the symptoms. The affection may be confined to the part in
immediate connection with the local disease, but in some cases the sub-
dural space over six or eight vertebrae is occupied by caseous masses.
Tlie cord at the site of the curvature in Pott's disease may be compressed,
with perhaps little or no involvement of the pia mater. The internal sur-
face of the dura may be perfectly smooth, perhaps a little adherent to the
arachnoid, while the external dura is thickened, rough, and covered with a
cheesy substance of a variable degree of consistence. In some instances
the dura is completely surrounded by this material ; in others it is chiefly
AFFECTIONS OF THE MENINGES. 821
on the anterior surface. We can understand the recovery in cases of com-
pression paraplegia if we bear in mind that in large part the actual com-
pression is produced by this material between the diseased vertebrae and
the dura mater. The symptoms are those of myelitis from compression,
often Avith signs of involvement of the nerve roots, such as will be men-
tioned in the next section.
(b) Pachymeningitis interna,, described by Charcot and Joifroy, in-
volves chiefly the cervical region {P. cervicalis hyper trophica). The
interspace between the cord and the dura is occupied by a firm, concen-
trically arranged, fibrinous growth, which is seen to have developed within,
not outside of, the dura mater. It is a condition anatomically identical
with the ha^morrhagic pachymeningitis interna of the brain. The cord
is usually compressed ; the central canal may be dilated — hydromyelus —
and there are secondary degenerations. The nerve roots are involved in
the growth and are damaged and compressed. The extent is variable.
It may be limited to one segment, but more commonly involves a con-
siderable portion of the cervical enlargement. The disease is chronic,
and in some cases presents a characteristic group of symptoms. There
are intense neuralgic pains in the course of the nerves whose roots are
involved. They are chiefly in the arms and in the cervical region, and
vary greatly in intensity. There may be hyperaesthesia with numbness and
tingling ; atrophic changes may develop, and there may be areas of anaes-
thesia. Gradually motor disturbances appear ; the arms become weak and
the muscles atrophied, particularly in certain groups, as the flexors of the
hand. The extensors, on the other hand, remain intact, so that the con-
dition of claw-hand is gradually produced. The grade of the atrophy
depends much upon the extent of involvement of the cervical nerve roots,
and in many cases the atrophy of the muscles of the shoulders and arms
becomes extreme. The condition is one of cervical paraplegia, with con-
tractures, flexion of the wrist, and typical main en griff e. Usually before
the arms are greatly atrophied there are the symptoms of what the French
writers term the second stage — namely, involvement of the lower extremi-
ties and the gradual production of a spastic paraplegia, which may develop
several months after the onset of the disease, and is due to secondary
changes in the cord.
The disease runs a chronic course, lasting, perhaps, two or more years.
In a few instances, in which symptoms pointed definitely to this condition,
recovery has taken place. The disease is to be distinguished from amyo-
trophic lateral sclerosis, syringomyelia, and tumors. From the first it is
separated by the marked severity of the initial pains in the neck and arms ;
from the second, by tlie absence of the sensory changes characteristic of
syringomyelia. From certain tumors it is very difficult to distinguish,
as, in fact, the fibrinous layers form a tumor around the cord.
The condition known as hmmatoma of the dura mater may occur at
any part of the cord, or, in its slow, progressive form — pachymeningitis
822 DISEASES OF THE NERVOUS SYSTEM.
haemorrliagica interna — may be limited to the cervical region and produce
the symptoms just mentioned. It is sometimes extensive, and may coexist
with a similar condition of the cerebral dura. Cysts may occur filled with
haemorrhasfic contents.
Diseases of the Pia Mater.
(a) Acute Spinal Meningitis; Leptomeningitis.
Etiology. — Spinal meningitis occurs : (1) In tuberculosis. This is
perhaps the most common form in general practice and has already been
considered. (2) In specific cerebro-spinal meningitis, which occurs en-
demically or epidemically, and has also been considered under its appro-
priate section. (3) As a secondary involvement in certain infectious dis-
eases, pneumonia, small-pox, scarlet fever, and typhoid fever. This form
is very rare Even in pneumonia, in which the cerebral meninges are
frequently involved, the spinal meninges are seldom affected, except per-
haps in the first two or three inches of the cervical region. (4) From in-
jury or the extension of inflammation, as after operation on spina bifida.
(5) There are cases in which the meningitis appears to have followed ex-
posure to cold and wet.
Morbid Anatomy. — The affection may be diffused over the entire
cord or localized to the cervical region. In the early stage the vessels of
the pia mater are injected. The fluid in the pia-arachnoid space is
slightly turbid. In some intense grades, on opening the dura the contour
of the cord cannot be seen, as it is completely enveloped in a sero-fibrin-
ous or purulent exudate, which here and there causes bulging of the
arachnoid. Owing to the position of the body, the exudate is most
abundant in the posterior part, or sinks to the lumbar region. In
acute cases the pia itself does not look thickened, but in more chronic
forms the membrane may be grayish and turbid. In a majority of in-
stances, if the inflammation is intense, the exudate is seen in the anterior
and posterior median fissures and the cortical portion of the cord is
swollen and infiltrated, so the condition can be properly called meningo-
myelitis. The affection may be limited to the spinal meninges, but in a
majority of instances it is a cerebro-spinal lesion.
Symptoms. — These have already been referred to in considering the
two commonest varieties, the tuberculous and the epidemic. The disease
often sets in with a chill and fever. Pain in the back, stiffness in the
neck, pain on pressure along the vertebra?, tremor or spasm of the mus-
cles, and disturbances of sensation arc usually present. Girdle sensations
are not common. The reflexes may be increased. Later, paral}'tic symp-
toms may develop, but they are uncommon, except in pure spinal men-
ingitis.
The diagnosis is often difficult. In a large proportion of the cases
supposed to be spinal meningitis the membranes are not inflamed. I have
AFFECTIO^^S OF THE MENINGES. 823
filready referred to the identity of the spinal symptoms in certain of the
infectious diseases with those of acute leptomeningitis. In the case of a
patient with high fever, marked stiffness of the back and neck muscles, or
opisthotonus with rigidity and tremor of the muscles, it is not unnatural
to make a positive diagnosis of spinal meningitis, but every symptom of
the condition may be present without any inflammatory exudate. The
truth of Stokes's dictum, already quoted (p. 25), has been brought home
to me on many occasions. On the other hand, there are instances of
well-marked leptomeningitis, more particularly the cerebro-spinal form,
in which spinal symptoms are trifling or absent. To distinguish between
the different forms of spinal meningitis is sometimes extremely difficult.
A correct diagnosis is oftenest made in tuberculous cases, since here the
prodromata are well defined and the symptoms indicative of involvement
of the cerebral meninges well marked. There are cases in which the
spinal meninges bear the brunt of the affection. I have already referred
to one case in which the meningitis was thought to be due to trauma-
tism. The coexistence of disease at the apex of the lungs or of local
tuberculous lesions elsewhere is of great value.
The diagnosis of the epidemic form has already been considered.
(b) Chronic Leptomeningitis. — As a primary lesion this is extremely
rare. It sometimes follows the prolonged use of alcohol. It occurs in
connection with syphilis, trauma, and as a complication of various scle-
roses of the spinal cord, either systemic or insular.
Anatomically the condition is characterized by a thickening and tur-
bidity of the pia, often with adhesions to the arachnoid and the dura.
The membranes may be stained with blood-pigment. These alterations
may occur in localized spots or over extensive areas. The nerve roots may
be involved and thickened. The spinal cord itself is rarely affected,
though strands of connective tissue may extend into the cortical zone,
producing slight sclerosis. The opaque, white, cartilaginous plates which
occur so often on the posterior surface of the spinal arachnoid and are
sometimes adherent to the pia cause no symptoms and are not to be mis-
taken for this chronic meningitis.
The symptoms of this form are indefinite. Simple thickening of the
meninges may produce no signs during life unless the spinal nerve roots
are involved. In any case the diagnosis is somewhat doubtful. There
are instances in which pain in the back, stiffness of the dorsal muscles,
and pains radiating in the nerves of the trunk or in the extremities have
been marked. II}7)er8esthesia and skin eruptions may be present. When
the cord is involved paralytic symptoms may develop. The reflexes are
increased. The course is always chronic, lasting for many years.
The treatment is purely symptornatic. liecovery probably never
occurs. ,
824 DISEASES OF THE NERVOUS SYSTEM.
HEMORRHAGE INTO THE SpINAL MeMBRANES ; H^MATORRHACHIS.
In meningeal apoplexy, as it is called, the blood may be between the
dura mater and the spinal canal — extrameningeal haemorrhage — or within
the dura mater — intrameningeal haemorrhage.
(a) Extramenijigeal Ilcemorrliage occurs usually as a result of trauma.
The exudation may be extensive without compression of the cord. The
blood comes from the large plexuses of veins which surround the dura.
The rupture of an aneurism into the spinal canal may produce extensive
and rapidly fatal haemorrhage.
(h) Intrameningeal Hcemorrhage is rather more common, but is rarely
extensive from causes acting directly on the spinal meninges themselves.
Scattered haemorrhages are not unfrequent in the acute infectious fevers,
and I have twice, in malignant small-pox, seen much effusion. Bleeding
occurs also in death from convulsive disorders, such as epilepsy, tetanus,
and strychnia poisoning. The most extensive haemorrhages occur in cases
in which the blood comes from rupture of an aneurism at the base of the
brain, either of the basilar or vertebral. In several cases of this kind I have
found a large amount of blood in the spinal meninges. In ventricular
apoplexy the blood may pass from the fourth ventricle into the spinal
meninges. There is a specimen in the medical museum of McGill College
of the most extensive intraventricular haemorrhage, in which the blood
passed into the fourth ventricle, and descended beneath the spinal arach-
noid for a considerable distance. On the other hand, haemorrhage into
the spinal meninges may possibly ascend into the brain.
The symptoms in moderate grades may be slight and indefinite. In
the non-traumatic cases the haemorrhage may either come on suddenly or
after a day or two of uneasy sensations along the spine. As a rule, the
onset is abrupt, with sharp pain in the back and symptoms of irritation in
the course of the nerves. There may be muscular spasms, or paralysis may
come on suddenly, either in the legs alone or both in the legs and arms.
In some instances the paralysis develops more slowly and is not complete.
There is no loss of consciousness, and there are no signs of cerebral dis-
turbance. The clinical picture naturally varies with the site of the haemor-
rhage. If in the lumbar region, the legs alone are involved, the reflexes may
be abolished, and the action of the bladder and rectum are impaired. In
the dorsal region there is more or less complete paraplegia, the reflexes are
usually retained, and there are signs of disturbance in the thoracic nerves,
such as girdle sensations, pains, and sometimes eruption of herpes. In the
cervical region the arms as well as the legs may be involved ; there may
be difficulty in breathing, stiffness of the muscles of the neck, and occa-
sionally pupillary symptoms.
The prognosis depends much upon the cause of the haemorrhage.
Recovery may take place in the traumatic cases, and in those associated
with the infectious diseases.
AFFECTIONS OF THE BLOOD-VESSELS. 825
11. AFFECTIONS OF THE BLOOD-VESSELS.
(a) Congestion. — Apart from actual myelitis, we rarely see post mor-
tem evidences of congestion of the spinal cord, and when we do it is usu-
ally limited either to the gray matter or to a definite j)ortion of the organ.
There is necessarily, from the posture of the body post mortem, a greater
degree of vascularity in the posterior portion of the cord. The white mat-
ter is rarely found congested, even when inflamed ; in fact, it is remarka-
ble how uniformly pale this portion of the cord is. The gray matter often
has a reddish-pink tint, but rarely a deep reddish hue, except when mye-
litis is present. If we know little anatomically of conditions of conges-
tion of the cord, we know less clinically, for there are no features in any
way characteristic of it.
(b) Anaemia. — So, too, with this state. There may be extreme grades
of anaemia of the cord without symptoms. In chlorosis and pernicious
anaemia there are rarely symptoms pointing to the cord, and there is no
reason to suppose that such sensations as heaviness in the limbs and tin-
gling are especially associated with anaemia.
There are, however, some very interesting facts with reference to the
profound anemia of the cord which follows ligature of the aorta. In ex-
periments made in Welch's laboratory by Herter, it was found that within
a few moments after the application of the ligature to the aorta paraplegia
came on. Paralysis of the sphincters developed, but less rapidly. Within
fourteen days contractures of the limbs set in with atrophy and fibrillar
twitchings. Histologically it was shown that within thirty-six hours there
were marked changes in the ganglion cells of the anterior horns in the
lumbar segments, and later there were signs of a definite myelitis. This
condition is of interest in connection with the fact of the rapid develop-
ment of a paraplegia after profuse haemorrhage, usually from the stomach
or uterus. It may come on at once or at the end of a week or ten days,
and is probably due to an anatomical change in the nerve elements similar
to that produced in Herter's experiments.
In this connection may be mentioned the interesting observations of
Lichtheim upon the degeneration of the posterior columns of the cord
in pernicious anaemia, of which he has reported three cases. He re-
gards it as a form of toxic myelitis, due to the altered condition of the
blood.
(c) Embolism and Thrombosis. — Blocking of the spinal arteries by em-
boli rarely occurs. It may be produced experimentally, and Money found
that it was associated with choreiform movements. Thrombosis of the
smaller vessels in connection with endarteritis plays an important part in
many of the acute and chronic changes in tlie cord.
{d) Endarteritis. — It is remarkable how frequently in persons over fifty
the arteries of the spinal cord are found sclerotic. The following forms
maybe met with: (1) A nodular peri-arteritis or endarteritis associated
826 DISEASES OF THE NERVOUS SYSTEM.
with syphilis and sometimes with gummata of the meninges ; (2) an arter-
itis obliterans, with great thickening of the intima and narrowing of the
lumen of the vessels, involving chiefly the medium and larger-sized arteries.
Miliary aneurisms or aneurisms of the larger vessels are rarely found in
the spinal cord. In the classical work of Leyden but a single instance of
the latter is mentioned.
(c) Hsemorrhage into the Spinal Cord {Hcematomyelia). — The existence
of a primary haemorrhage into the cord has been denied on the ground
that in all instances it is preceded by a condition of softening. A majority
of authors, however, admit the existence of a primary form. About forty-
two cases are on record, which are collected in the thesis of Hayem * and
in the article of Berkeley, f It is more common in males than in females,
and at the middle period of life. The cases have followed either cold and
exposure or overexertion, and, most frequently of all, traumatism. It oc-
curs also in tetanus and convulsions. Haemorrhage may be associated with
tumors, with syringo-myelia, or with myelitis ; it is often difficult to de-
termine whether the case is one of primary haemorrhage with myelitis, or
myelitis with a secondary haemorrhage.
The anatomical condition is very varied. The cord may be enlarged
at the site of the haemorrhage, and occasionally the white substance may
be lacerated and blood may escape beneath the meninges. The extravasa-
tion is chiefly in the gray matter, and may be limited or focal, or very
diffuse, extending a considerable distance in the cord. In a case which
occurred at the Montreal General Hospital under Wilkins the haemorrhage
occupied a position opposite the region of the fifth and sixth cervical
nerves and on transverse section the cord was occupied by a dark-red clot
measuring twelve by five millimetres, around which the white substance
formed a thin, ragged wall. The clot could be traced upward as far as the
second cervical, and downward as far as the fourth dorsal.
The sudden onset of the spnptonis is the most characteristic feature
in haematomyelia. The loss of power necessarily varies with the locality
affected. If in the cervical region, both arms and legs may be involved ;
but if in the dorsal or lumbar, there is only paraplegia. There is usually
loss of sensation, and at first loss of reflexes. Myelitis frequently develops
and becomes extensive, with fever and trophic changes. The. condition
may rapidly prove fatal ; in other instances there is gradual recovery, often
with partial paralysis.
The diagnosis may be made in some instances, particularly those in
which the onset is sudden after injury, but there is great difficulty in dif-
ferentiating ha^morrhagic myelitis from certain cases of haemorrhage into
the spinal meninges. The question of diagnosis has been carefully consid-
ered by Hoch J in a recent report of two cases from my clinic.
* Paris, 1872.
t Brain, 1889.
X Johns Hopiiins Hospital Reports, vol. ii, fasciculus 6.
AFFECTIONS OF THE BLOOD-VESSELS. 827
(/) Caisson Disease; Diver's Paralysis. — This remarkable affection,
found in divers and in workers in caissons, is characterized by a paraplegia,
more rarely a general palsy, which supervenes on returning from the com-
pressed atmosphere to the surface.
The disease has been carefully studied by the French writers, by Ley-
den and Schultze in Germany, and in this country particularly by A. 11.
Smith. The pressure must be more than that of three atmospheres. The
symptoms are especially apt to come on if the change from the high to
the ordinary atmospheric pressure is quickly made. They may supervene
immediately on leaving the caisson, or they may be delayed for several hours.
In the mildest form there are simply pains about the knees and in the
legs, often of great severity, and occurring in paroxysms. Abdominal
pain and vomiting are not uncommon. The legs may be tender to the
touch, and the patient may walk with a stiff gait. Dizziness and headache
may accompany these neuralgic symptoms, or may occur alone. More
commonly in the severe form there is paralysis both of motion and sen-
sation, usually a paraplegia, but it may be general, involving the trunk
and arms. Monoplegia and hemiplegia are rare. In the most extreme
instances the attacks resemble apoplexy, and the patient rapidly becomes
comatose and death occurs in a few hours. In the cases of paraplegia the
outlook is usually good, and the paralysis may pass off in a day, or may
continue for several weeks or even for months. Identical features are
met with in the deep-sea divers.
The explanation of this condition is by no means satisfactory. Two
careful autopsies have been made. In Leyden's case death occurred on
the fifteenth day, and in the dorsal portion of the cord there were numer-
ous foci of haemorrhages and signs of an acute myelitis. In Schultze's
case death occurred in two and a half months, and a disseminated myelitis
was found in the dorsal region. In both cases there were fissures, and
appearances as if tissue had been lacerated. It has been suggested that
the symptoms are due to the liberation in the spinal cord of bubbles of
nitrogen which have been absorbed by the blood under the high pressure,
and the condition found at the autopsies Just referred to is held to favor
this view.
A large majority of the cases recover. The severe neuralgic pains
often require morphia. Inhalations of oxygen and the use of compressed
air have been advised. When paraplegia develops the treatment is similar
to that of other forms. In all caisson work care should be exercised that
the time in passing through the lock from the high to the ordinary press-
ure be sufficiently prolonged. According to A. II. Smith, at least five
minutes should be allowed for each additional atmosphere of pressure.
828 DISEASES OP THE NERVOUS SYSTEM.
III. ACUTE AFFECTIONS OF THE SPINAL CORD,
(1) Acute Diffuse Myelitis.
Etiology. — Acute myelitis results from many causes, and may affect
the cord in a limited or extended portion — the gray matter chiefly, or the
gray and white matter together. It is met with : (a) As an independent
affection following exposure to cold, or exertion, and leading to rapid
loss of power with the symptoms of an acute ascending paralysis, (b) As
a sequel of the infectious diseases, such as small-pox, typhus, and measles.
(c) As a result of traumatism, either fracture of the spine or very severe
muscular effort. Concussion without fracture may produce it, but this is
rare. Acute myelitis, for instance, scarcely ever follows railway accidents.
(d) In disease of the bones of the spine, either caries or cancer. This is a
more common cause of localized acute transverse myelitis than of the diffuse
affection, (e) In disease of the cord itself, such as tumors and syphilis ;
in the latter, either in association with gummata, in which case it is
usually a late manifestation, or it may follow within a year or eighteen
months of the primary affection.*
Morbid Anatomy. — In localized acute myelitis affecting white and
gray matter, as met with after accident or an acute compression, the cord is
swollen, the pia injected, the consistence greatly reduced, and on incising
the membrane an almost diffluent fluid may escape. In less intense
grades, on section at the affected area, all trace of distinction between the
gray and white matter is lost, or extremely indistinct. The tissue may be in-
jected, or, as is often the case, haemorrhagic. It is particularly in these
forms, due to extension of disease from without or to acute compression,
that we find definite involvement of the white matter. In other instances
the gray matter is chiefly affected. There may be localized areas through-
out the cord in which the gray matter is reduced in consistence and
haemorrhagic, the so-called red softening. There may be definite cavity
formations in these foci. In some cases of disseminated or focal myelitis
the meninges also are involved and there is a myelo-meningitis. And,
lastly, there are instances in which, throughout a long section of the cord,
sometimes through the lumbar and the greater part of the dorsal, or in the
dorsal and cervical regions, there is a diffuse myelitis of the gray sub-
stance.
Histologically the nerve fibres are much swollen and irregularly dis-
torted, the axis cylinders are beaded, the myelin droplets are abundant,
and the laminated bodies known as corpora amylacca may be seen. The
granular fatty cells are also numerous and there may be leucocytes and
red l)lood-corpuscles. Changes in the blood-vessels are striking; the
smaller veins are distended and may show varicosities. The perivascular
* Brcteau, Des Maladies Sypliilitiques Precoces, Paris Thesis, 1889.
ACUTE AFFECTIONS OF THE SPINAL CORD. 829
lymph spaces contain numerous leucocytes, and the smaller arteries them-
.selves are frequently the seat of hyaline thrombi. The ganglion cells
are swollen and irregular in outline, the protoplasm is extremely granu-
lar and vacuolated, and the nuclei, though usually invisible, may show
signs of division, and the processes of the cells are not seen.
In cases which persist for some time we have an opportunity of seeing
the later stages of acute myelitis. The acute, inflammatory, hyjDcrgemic or
red softening is succeeded by stages in which the affected area becomes
more yellow from gradual alteration of the blood-pigment, and finally
white in color from the advancing fatty degeneration. In cases of com-
pression myelitis, a sclerosis may gradually be produced with the anatom-
ical picture of a chronic diffuse myelitis.
Symptoms. — {a) Acute Central Myelitis. — It is this form which
comes on spontaneously after cold, or in connection with syphilis or one
of the infectious diseases, or is seen in a typical nianner in the extension .
from injuries or from tumor. The onset, though scarcely so abrupt as in
haemorrhage, may be sudden ; a person may be attacked on the street and
have difficulty in getting home. In some instances, the onset is preceded
by pains in the legs or back, or a girdle sensation is present. It may
be inarked by chills, occasionally by convulsions ; fever is usually present
from the beginning — at first slight, but subsequently it may become
high.
The motor functions are rapidly lost, sometimes as quickly as in Lan-
dry's ascending paralysis. The paraplegia may be complete, and, if the
myelitis extends to the cervical region, there may be impairment of mo-
tion, and ultimately complete loss of power of the upj)er extremities as
well. The sensation is lost, but there may at first be hyperaesthesia. The
reflexes in the initial stage are increased, but in acute central mj^elitis, un-
less limited in extent to the dorsal and cervical regions, the reflexes are
usually abolished. The rectum and bladder are paralyzed. Trophic dis-
turbances are marked ; the muscles waste rapidly ; the skin is often con-
gested, and there may be localized sweating. The temperature of the
affected limbs may be lowered. Acute bed-sores may develop over the
sacrum or on the heels, and sometimes a multiple arthritis is present. In
these acute cases the general symptoms become greatly aggravated, the
pulse is rapid, the tongue becomes dry; there is delirium, the fever in-
creases, and may reach 107° or 108°.
The course of the disease is variable. In very acute cases death follows
in from five to ten days. The cases following the infectious diseases par-
ticularly the fevers and sometimes syphilis, may run a milder course.
The diagnosis of this variety of acute myelitis is rarely difficult. In
common with the acute ascending paralysis of Landry, and with certain
cases of multiple neuritis, it presents a rapid and progressive motor paraly-
sis. From the former it is distinguished by the more marked involvement
of sensation, the trophic disturbances, the paralysis of bladder and rectum,
830 DISEASES OF THE NERVOUS SYSTEM.
the rapid wasting, the electrical changes, and the fever. From acute cases
of multiple neuritis it may be more difficult to distinguish, as the sensory
features in these cases may be marked, though there is rarely, if e^er, in
multiple neuritis complete anaesthesia; the wasting, moreover, is more
rapid in myelitis. The bladder and rectum are rarely in\olved — though
in exceptional cases they may be — and, most important of all, the troi3hic
changes, the development of bullae, bed-sores, etc., are not seen in multiple
neuritis.
{!)) Acute Transverse Myelitis. — The symptoms naturally differ with
the situation of the lesion.
(1) Acute transverse myelitis in the dorsal region^ the most common
situation, produces a very characteristic picture. The symptoms of onset
are variable. There may be initial pains or numbness and tingling in the
legs. The paralysis may set in quickly and become complete within a
few days ; but more commonly it is preceded for a day or two by sensa-
tions of pain, heaviness, and dragging in the legs. The paralysis of the
lower limbs is usually complete, and if at the level, say, of the sixth dorsal
vertebra, the abdominal muscles are involved. Sensation may be partially
or completely lost. At the onset there may be numbness, tingling, or even
hyperaesthesia in the legs. At the level of the lesion there is often a zone
of hyperaesthesia, which is discovered by passing a test-tube containing hot
water along the spine, when the sensation of warmth changes to one of
actual pain. A girdle sensation may occur early, and when the lesion is in
this situation it is usually felt between the ensiform and umbilical regions.
The reflex functions are variable. There may at first be abolition of the re-
flexes ; subsequently, the reflexes, passing through the segments lower than
the one affected, may be exaggerated and the limbs may pass into a con-
dition of spastic rigidity. It does not always happen, however, that the re-
flexes are increased in a total transverse lesion of the cord. They may be
entirely lost, as pointed out some years ago by Bastian, and insisted upon by
him in a recent memoir.* F. T. Miles has also called attention to this fact
and reported five cases in which the reflexes were lost in total transverse
lesion of the cord. That this is not due to the preliminary shock is shown
by the fact that the abolition of the reflexes may continue for four or mor6
months. The trophic changes are not marked. The muscles become ex-
tremely flabby, but not wasted in an extreme degree ; subsequently rigidity
develops. If the gray matter of the lumbar cord is involved, the flaccidity
persists and the wasting may be considerable. The reaction of degenera-
tion is not present. The temperature of the paralyzed limbs is variable.
It may at first rise, then fall and become subnormal. Lesions of the skin
are not uncommon, and bed-sores are apt to form. There is at first re-
tention of urine and subsequent incontinence. If the lumbar centres are
involved, there are from the outset vesical symptoms. The urine is alka-
* Medico-Chirurgical Transactions, vol. Ixxiii.
ACUTE AFFECTIONS OF THE SPINAL CORD. 831
line in reaction and may ra2)iclly become ammoniacal. The bowels are
constipated and there is usually incontinence of the faeces. Some writers
attriljute the cystitis associated Avitli transverse myelitis to disturbed tro-
phic influence.
The course of complete transverse myelitis depends a good deal upon
its cause. Death may result from extension. Segments of the cord may
be completely and permanently destroyed, in which case there is persistent
paraplegia. The pyramidal fibres below the lesion undergo the secondary
degeneration, and there is an ascending degeneration of the posterior me-
dian columns. If the lower segments of the cord are involved the legs
may remain flaccid. In some instances a transverse myelitis of the dorsal
region involves the anterior horns above and below the lesion, producing
flaccidity of the muscles, with wasting, fibrillar contractions, and the reac-
tion of degeneration. More commonly, however, in the cases which last
many months there is more or less rigidity of the muscles with spasm or
persistent contraction of the flexors of the knee.
(2) Transverse Myelitis of the Cervical Region. — If at the level of the
sixth or seventh cervical nerves, there is paralysis of the upper extremities,
more or less complete, sometimes sparing the muscles of the shoulder.
Gradually there is loss of sensation. The paralysis is usually complete be-
low the point of lesion, but there are rare instances in which the arms only
are affected, the so-called cervical paraplegia. In addition to the symp-
toms already mentioned there are several which are more characteristic of
transverse myelitis in the cervical region, such as the occurrence of vomit-
ing, hiccough, and slow pulse, which may sink to twenty or thirty, pupillary
changes — myosis — sometimes attacks of dysphagia, dyspnoea, or syncope.
II. Myelitis of the Anterior Horns
{Polio-7nyelitis Anterior ; Atrophic Spi7ial Paralysis).
Definition. — An affection occurring most commonly within the first
three years of life, characterized by fever, loss of power in certain mus-
cles, and rapid atrophy.
Etiology. — The cause of the disease is unknown. It has been at-
tributed to cold, to the irritation from dentition, or to overexertion.
Since the days of Mephibosheth, i:)arents have been inclined to attribute
this form of paralysis to the carelessness of nurses in letting the children
fall, but very rarely is the disease induced Ijy traumatism, and in perhaps a
majority of the cases the child is attacked while in full health. As Sinkler
has pointed out, the cases are more common in the warm months. Boys
are more liable to be affected than girls. Several instances of the occur-
rence of numerous cases together in epidemic form have been described.
Medin reports from Stockholm an epidemic in which from the 9th of
August to the 23d of September 29 cases came under observation. In two
instances two children in the same family were attacked within a few days.
S32 DISEASES OF THE NERVOS SYSTEM.
Although most frequent in children, it develops occasionally in young
adults, or even in middle-aged persons.
Morbid Anatomy. — The disease is oftenest seen in either the cer-
vical or lumbar enlargements. In very early cases, such as those de-
scribed by David Drummond and Charlewood Turner, the lesion has been
that of an acute haemorrhagic myelitis with degeneration and rapid de-
struction of the large ganglion cells. The condition may be strictly con-
fined to the anterior cornua ; in some instances there is slight meningeal
involvement. In cases in which the examination is not made for some
months or years the changes are very characteristic. The anterior cornu
in the affected region is greatly atrophied and the large motor cells are
either entirely absent or only a few remain. The affected half of the cord
may be considerably smaller than the other. The antero-lateral column
may show slight sclerotic changes, chiefly in the pyramidal tract. The
corresponding anterior nerve roots are atrophied, and the muscles are
wasted and gradually undergo a fatty and sclerotic change.
Symptoms. — In a majority of the cases, after slight indisposition
and feverishness, the child is noticed to have lost the use of one limb.
Convulsions at the outset are rare, not constant as in the acute cerebral
palsies of children. Fever is usually present, the temperature rising to
101°, sometimes to 103°. Pain is rarely complained of ; there may oc-
casionally be slight aching in the joints. The paralysis is abrupt in
its onset and, as a rule, is not progressive, but reaches its maximum
in a very short time, even within twenty-four hours. It is rarely gen-
eralized. The suddenness of onset is remarkable and suggests a pri-
mary affection of the blood-vessels, a view which the haemorrhagic char-
acter of the early lesion supports. The distribution of the paralysis is
very variable. One or both arms may be affected, one arm and one leg,
or both legs ; or it may be crossed paralysis, the right leg with the left
arm. In the upper extremities the paralysis is rarely complete and groups
of muscles may be affected. As Eemak has pointed out, there is an
upper-arm and a lower-arm type of palsy. The deltoid, the biceps, bra-
chiidis anticus, and supinator longus may be affected in the former, and
in the latter the extensors or flexors of the fingers and wrists. This dis-
tribution is due to the fact that the groups of nerve-cells are attacked
which preside over certain muscles acting functionally together.
In the legs the tibialis anticus and extensor groups of muscles are more
affected than the hamstrings and glutei. The muscles of the face are
never, the sphincters rarely, involved. While the rule is for the paralysis
to be abrupt and sudden, there are cases in which it comes on slowly and
takes from three to five days for its development. At first the affected
limb looks natural, and as children between two and three are usually fat,
very little change may be noticed for some time ; but the atrophy pro-
ceeds rapidly, and the limb becomes flaccid and feels soft and flabby.
Usually as early as the end of the first week the reaction of degeneration
ACUTE AFFECTIONS OF THE SPINAL COIID. 833
is present. The nerves are found to have lost their irritability. The
muscles do not react to the induced current, but to the constant current
they respond by a sluggish contraction, usually to a weaker current than
is normal, and more to the positive pole than to the negative. The paraly-
sis remains stationary for a time, and then there is gradual improvement.
Complete recovery is rare, and, when the anatomical condition is consid-
ered, is scarcely to be expected. The large motor cells of the cornua,
when thoroughly disintegrated, cannot be restored. In too many cases
the improvement is only slight and permanent paralysis remains in cer-
tain groups. Sensation is unaffected ; the skin reflexes are absent, and
the deep reflexes are usually lost.
When the paralysis persists the wasting is extreme, the growth of the
bones of the affected limb is arrested, or at any rate retarded, and the
joints may be very relaxed ; as, for instance, when the deltoid is affected
the head of the humerus is no longer kept in contact with the glenoid
cavity. In the later stages very serious deformities are produced by the
contracture of the muscles.
Diagnosis. — The condition is only too evident in the majority- of
cases. There is a flaccid, flabby paralysis of one or more limbs which has
set in abruptly. The rapid wasting, the lax state of the muscles, the
electrical reactions, and the absence of reflexes distinguish it from the
cerebral palsies. The pseudo-paresis of rickets is a condition to be care-
fully distinguished. In this the loss of power is in the legs, rapid atrophy
is not present, certain movements are possible but painful. The general
hyperaesthesia of the skin, the characteristic changes in the bones, and the
diffuse sweats are present. Disease of the hip or knee may produce a
pseudo-paralysis which can with care be readily distinguished.
Prognosis. — The outlook in any case for complete recovery is bad.
The natural course of the disease must be borne in mind; the sudden
onset, the rapid but not progressive loss of power, a stationary period, then
marked improvement in certain muscle groups, and finally in many cases
contractures and deformities. There is no other disease in which the
physician is so often subject to unjust criticism, and the friends should be
told at the outset that in the severe and extensive paralysis complete
recovery should not be expected. The best to be hoped for is a gradual
restoration of power in certain muscle groups. In estimating the probable
grade of permanent paralysis, the electrical examination is of great value.
Treatment of Acute Myelitis. — In the rapidly developing form
due either to a diffuse inflammation in the gray matter or to transverse
myelitis, the important measures are : Scrupulous cleanliness, care and
watchfulness in guarding against bed-sores, the avoidance of cystitis, either
by systematic catheterization or, if there is incontinence, by a carefully
adjusted bed urinal, or the use of antiseptic cotton -wool repeatedly
changed. In an acute onset in a healthy subject the spine may be cuj^pcd.
Counter-irritation is of doubtful advantage. Chapman's ice-bag is some-
S3-i DISEASES OF THE NERVOUS SYSTEM.
times useful. No drugs have the slightest influence upon an acute myelitis,
and even in subjects with well-marked syphilis neitlier mercury nor iodide
of potassium is curative. Tonic remedies, such as quinine, arsenic, and
strychnia, may be used in the later stages. AVhen the muscles have wasted,
massage is beneficial in maintaining their nutrition. Electricity should
not be used in the early stages of myelitis. It is of no value in the trans-
verse myelitis in the dorsal region with retention of the nutrition in the
muscles of the leg.
The treatment of acute infantile paralysis has a bright and a dark side.
In a case of any extent complete recovery cannot be expected ; on the
other hand, it is remarkable how much improvement may finally take
place in a limb which is at first completely flaccid and helpless. The fol-
lowing treatment may be pursued : If seen in the febrile stage, a brisk
laxative and a fever mixture may be given. The child should be in bed
and the aifected limb or limbs wrapped in cotton. As in the great majority
of cases the damage is already done when the physician is called and the
disease makes no further progress, the application of blisters and other
forms of counter-irritation to the back is irrational and only cruel to the
child.
The general nutrition should be carefully maintained by feeding the
child well, and taking it out of doors every day. As soon as the child can bear
friction the affected part should be carefully rubbed ; at first once a day,
subsequently morning and evening. Any intelligent mother can be taught
systematically to rub, knead, and pinch the muscles, using either the bare
hand or, better still, sweet oil or cod-liver oil. This is worth all the other
measures advised in the disease, and should be systematically practised for
months, or even, if necessary, a year or more. Electricity has a much
more limited use, and cannot be compared with massage in maintaining
the nutrition of the muscles. The faradic current should be applied to
those muscles which respond. The essence of the treatment is in main-
taining the nutrition of the muscles, so that in the gradual improvement
which takes place in parts, at least, of the affected segments of the cord
the motor impulses may have to deal with well-nourished, not atrophied
muscle fibres.
Of medicines, in the early stage ergot and belladonna have been
warmly recommended, but it is unlikely that they have the slightest
influence. Later in the disease strychnia may be used witli advantage in
one or two minim doses of the liquor strychninae, which, if it has no other
effect, is a useful tonic.
The most distressing cases are those which come under the notice of
the physician six, eight, or twelve months after the onset of the paralysis,
when one leg or one arm or both legs are flaccid and have little or no
motion. Can nothing be done ? A careful electrical test should be made
to ascertain which muscles respond. Tliis may not be apparent at first,
and several applications may be necessary before any contractility is
ACUTE AFFECTIONS OF THE SPINAL CORD. 835
noticed. With a few lessons an intelligent mother can be taught to use
the electricity as well as to apply the massage. If in a case in which the
paralysis has lasted for six or eight months no observable improvement
takes place in the next six months with thorough and systematic treat-
ment, little or no hope can be entertained of further change.
In the later stage care should be taken to prevent the deformities
resulting from the contractions. Great benefit results from a carefully
applied apparatus.
III. Acute and Subacute Polio-myelitis ii^ Adults.
An acute polio-myelitis in adults, the exact counterpart of the disease
in children, is recognized. A majority, however, of the cases described
under this heading have been multiple neuritis ; but the suddenness of
onset, the rapid wasting, and the marked reaction of degeneration are
thought by some to be distinguishing features. Multiple neuritis may,
however, set in with rapidity ; there may be great wasting and the reaction
of degeneration is sometimes present. The time element alone may deter-
mine the true nature. Eecovery in a case of extensive multiple paralysis
from polio-myelitis will certainly be with loss of power in certain groups
of muscles; whereas, in multiple neuritis the recovery, while slow, may
be perfect.
The subacute form, the paralysie generate spinale anterieiire sulaigue
of Duchenne, is in all probability a peripheral palsy. The paralysis usually
begins in the legs with atrophy of the muscles, then the arms are involved,
but not the face. Sensation is, as a rule, not involved.
IV. Acute Ascending (Landry's) Paralysis.
Definition. — An advancing paralysis, beginning in the legs, rapidly
extending to the trunk and arms, and finally, in many cases, involving the
muscles of respiration. It presents a remarkable similarity in its symp-
toms to certain cases of polyneuritis, with which it is now grouped by
many writers.
Etiology and Pathology. — The disease occurs most commonly in
males between the twentieth and thirtieth years. It has sometimes fol-
lowed the specific fevers. An elaborate study of 93 cases collected from
the literature has been made by James Ross, who concludes that in etiol-
ogy, symptoms, course, and termination it conforms to a peripheral neu-
ritis. Neuwerk and Barth have reached a similar conclusion. In their
case an interstitial neuritis was found in the nerve roots, but the peripheral
nerves were normal. On the other hand, cases have been reported of
rapidly ascending paralysis in which the periphral nerves and nerve roots
were unalfected. In a case of eleven days' duration recently studied by
Ilun, the lesions were certainly too slight to account for the advancing
and wide-spread paralysis, and, with our present knowledge, Hun is cor-
53
836 DISEASES OF THE NERVOUS SYSTEM.
rect in stating that " acute ascending paralysis — defined so as to exclude
all cases in which the sensory symptoms are prominent, or in which well-
marked bulbar symptoms are not present — must therefore be regarded as
a clinical entity for which no corresponding lesion has as yet been discov-
ered." It is not improbable that some toxic agent is responsible for the
symptoms.
Symptoms. — AVeakness of the legs, gradually progressing, often
with tolerable rapidity, is the first symptom. In some qases within a few
hours the paralysis of the legs becomes complete. The muscles of the
trunk are next affected, and within a few days, or even less in more acute
cases, the arms are also involved. The neck muscles are next attacked,
and finally the muscles of respiration, deglutition, and articulation. The
reflexes are lost, but the muscles neither waste nor show electrical changes.
The sensory symptoms are variable ; in some cases tingling, numbness, and
hyperaesthesia have been present. In the more characteristic cases sensa-
tion is intact and the sphincters are uninvolved. Enlargement of the
spleen has been noticed in several cases. The course of the disease is
variable. It may prove fatal in less than two days. Other cases persist
for a week or for two weeks. In some instances recovery has occurred, but
in a large proportion of the cases the disease is fatal.
The diagnosis is difficult, particularly from certain forms of multiple
neuritis, and if we include in Landry's paralysis the cases in which sensa-
tion is invoRed, distinction between the two affections is impossible. We
apparently have to recognize the existence of a rapidly advancing motor
paralysis without involvement of the sphincters, without wasting or elec-
trical changes in the muscles, without trophic lesions, and without fever —
features sufficient to distinguish it from either the acute central myelitis
or the polio-myelitis anterior. It is doubtful, however, whether these
characters always suffice to enable us to differentiate the cases of multiple
neuritis.
IV. CHRONIC AFFECTIONS OF THE SPINAL CORD.
I. Spastic Paraplegia.
Definition. — Loss of power with spasm of the muscles of the lower
extremities.
While clinically spastic paraplegia, or, as it is sometimes called, tahes
dorsalis spasmodique^ is a well-defined, readily recognizable affection, etio-
logically and anatomically it presents marked differences, and various
groups must be separated, all of which present, however, the combination
of spasm with loss of power. As the pyramidal tracts are involved, the
term lateral sclerosis is sometimes used as the equivalent of spastic para-
plegia. I shall consider the following forms :
CimONIC AFFECTIONS OF THE SPINAL CORD. 837
(1) Secondary Spastic Paralysis. — After any tranverse lesion of the
cord, whetlier the result of slow compression (as in caries), chronic mye-
litis, the pressure of tumor, chronic meningo-myelitis, or multiple sclerosis,
degeneration takes place in the pyramidal tracts below the point of dis-
ease. The legs soon become stiif and rigid, and the reflexes increase. It
happens occasionally, as Bastian has shown, that in compression para-
plegia the limbs may be flaccid without increase in the reHexeB—paraplef/ie
flasqiie of the French. The condition of the patient in these secondary
forms varies very much. In chronic myelitis or in multiple sclerosis he
may be able to walk about, but with a characteristic spastic gait. In the
compression myelitis, in fracture, or in caries, there may be complete loss
of power with rigidity.
(2) Primary Spastic Paraplegia.— This is believed to depend upon a
primary sclerosis of the lateral or pyramidal tracts. Clinically it is com-
mon to meet with cases in adults, particularly in syphilitic subjects, who
have pains in the back, perhaps a girdle sensation, and a gradually devel-
oping, progressive spastic paraplegia. It may be impossible from the
history or the physical examination to determine whether the condition
is secondary to a transverse myelitis or a meningo-myelitis, or whether the
lesion is a primary degeneration of the pyramidal tracts. The question is
still debated whether a primary lesion of the lateral tracts ever takes place,
or whether, in such instances, there is not always some lesion of the motor
cells in the anterior horns. Cases may persist for years without any
atrophy. In other instances there are signs of involvement of the posterior
columns as well, forming the condition of ataxic paraplegia, which will
be considered separately. So far as I know, the only case which is claimed
to demonstrate the existence of a primary lateral sclerosis is that of Dresch-
feld's, which occurred in 1881.
The symptoms of spastic paraplegia are very distinctive. The patient
complains of feeling tired, of stiffness in the legs, and perhaps of pains of a
dull aching character in the back or in the calves. There may be no defi-
nite loss of power, even when the spastic condition is well established. In
other instances there is definite weakness. The stiffness is felt most in
the morning. In a well-developed case the gait is most characteristic.
The legs are moved stiffly and with hesitation, the toes drag and catch
against the ground, and, in extreme cases, when the ball of the foot rests
upon the ground a distinct clonus develops. The legs are kept close
together, the knees touch, and in certain cases the adductor spasm may
cause cross-legged progression. On examination, the legs may at first
appear tolerably supple, perhaps flexed and extended readily. In other
cases the rigidity is marked, particularly when the limbs are extended.
The spasm of the adductors of the thigh may be so extreme that the
legs are separated with the greatest difficulty. In cases of this extreme
rigidity the patient usually loses the power of walking. The nutrition is
well maintained, the muscles may be hypertrophied. The reflexes are greatly
83S DISEASES OF THE NERVOUS SYSTEM.
increased. The slightest touch upon the patellar tendon produces an active
knee-jerk. The rectus clonus and the ankle clonus are easily obtained.
In some instances the slightest touch may throw the legs into violent
clonic spasm, the condition to which Brown-Sequard gave the name of
spinal epilepsy. The superficial reflexes are also increased. The arms
may be unaffected for years, but as a late manifestation rigidity may
develop.
The diagnosis is readily made, but it is often very difficult to determine
accurately the nature of the underlying pathological condition. A history
of s}T3hilis is present in many of the cases. The course of the disease is
progressively downward. Years may elapse before the patient is bed-
ridden. Involvement of the sphincters, as a rule, is late ; occasionally,
however, it is early. The sensory symptoms rarely progress and the
patients may retain the general nutrition and enjoy excellent health.
Ocular symptoms are rare.
(3) The Spastic Paraplegia of Infants {Paraplegia Cerehralis Spastica
— Heine). — This is usually a birth palsy, often the result of difficult labor.
In twenty-three of the twenty-four of Little's cases, there was either diffi-
cult labor or premature delivery. Several children may be affected in a
family. Gee reports two cases in one family, Schultze three, and with
Latimer I saw a brother and a sister with the disease. In this connection
it is interesting to note that Bernhardt has recently described a family
form of spastic paraplegia, in which four brothers were affected, the dis-
ease developing in each about the thirtieth year. The stiffness of the
legs may not be noticed for some months after birth, but usually on dress-
ing the child the mother notices the rigidity. When attempts are made
to walk the stiffness and awkwardness then become apparent. On stand-
ing, the attitude is very characteristic. There is talipes equinus, varying
from the slightest raising of the heel to a condition in which the child
stands on tiptoe. In older children, as they walk, the toe-cap of the shoe
is usually much worn. The strong adductor action may produce typical
cross-legged progression, in which each foot is dragged over and planted
in front, or even on the other side of its fellow. In attempting to flex
the legs there is a marked resistance, whioh gradually yields — the lead-
pipe contraction, as Weir Mitchell calls it. The reflexes are increased,
though in some children it is not an easy matter to obtain them. The
ankle clonus, as a rule, is not obtainable. Sensation is unimpaired, and
the bladder and rectum are not involved.
The symptoms of this affection in children are almost identical with
the spastic paraplegia of adults. The arms may be involved — spastic
diplegia. The disease is probably of cortical origin. There are frequently
symptoms indicating cerebral defects, such as idiocy, imbecility, and
nystagmus. Some of the cases depend, no doubt, upon bilateral meningeal
haemorrhage occurring during delivery. Others are probably due to arrest
of development of the pyramidal tracts. This condition in children must
CHRONIC AFFECTIONS OF THE SPINAL CORD. 839
not be confounded with tetany or with the pseudo-paralytic rigidity so
often associated with rickets.
(4) Ataxic Paraplegia. — This name is applied by Gowers to a disease
characterized clinically by a combination of ataxia and spastic paraplegia,
and anatomically by involvement of the posterior and lateral columns.
The disease is most common in middle-aged males. Exposure to cold
and traumatism have been occasional antecedents. In striking contrast
to ordinary tabes a history of syphilis is rarely to be obtained.
The anatomical features are a sclerosis of the posterior columns, which
is not more marked in the lumbar region and not specially localized in
the root zone of the postero-external columns. The involvement of the
lateral columns is diffuse, not always limited to the pyramidal tracts, and
there may be an annular sclerosis.
The symptoms are well defined. The patient complains of a tired
feeling in the legs, not often of actual pain. The sensory symptoms of
true tabes are absent. An unsteadiness in the gait gradually develops
with progressive weakness. The reflexes are increased from the outset,
and there may be well-developed ankle clonus. Eigidity of the legs
slowly comes on, but is rarely so marked as in the uncomplicated cases
of lateral sclerosis. From the start, incoordination is a well-characterized
feature, and the difficulty of walking in the dark or swaying when the
eyes are closed may, as in true tabes, be the first symptom to attract atten-
tion. In walking the patient uses a stick, keeps the eyes fixed on the
ground, the legs far apart, but the stamping gait, with elevation and sud-
den descent of the feet, is not often seen. The incoordination may extend
to the arms. Sensory symptoms are rare, but Gowers calls attention to a
dull, aching pain in the sacral region. The sphincters usually become
involved. Eye symptoms are rare. Late in the disease mental symptoms
may develop, similar to those of general paresis.
In well-marked cases the diagnosis is easy. The combination of
marked incoordination with retention of the reflexes and more or less
spasm are characteristic features. The absence of ocular and sensory
symptoms is an important point.
(5) Hysterical Spastic Paraplegia. — There is no spinal-cord disease
which may be so accurately mimicked by hysterical patients as spastic
paraplegia. There is wasting in the hysterical paraplegia, the sensory
symptoms are not marked, the loss of power is not complete, and there is
not that extensor spasm so characteristic of organic disease. The hyster-
ical contracture will be considered later.
The reflexes are, as a rule, increased. The knee-jerk is present, and
there may be well-developed ankle clonus. Gowers calls attention to the
fact that it is usually a spurious clonus, " due to a half-voluntary contrac-
tion in the calf muscles." A true clonus does occur, however, and there
may be the greatest difficulty in determining whether or not the case is
one of hysterical paraplegia.
g-J-O DISEASES OF THE NERVOUS SYSTEM.
(6) Primary Combined Sclerosis (Putnam). — In addition to the ataxic
paraplegia just mentioned, here may be considered certain cases which are
characterized anatomically by a relatively chronic sclerosis of the posterior
columns, of the lateral columns, chiefly the pyramidal tract, and also of
the cerebellar tract. With these are usually associated more acute changes
in adjoining areas, either diffuse or systemic, some grade of degeneration
in the gray matter, and involvement of the nerve roots. This form has
been studied by J. J. Putnam and Dana. The cases are usually in women
— seven out of nineteen collected by Dana ; the ages, from forty-five to
sixty-four. The disease runs a rather rapid course. Neuropathic inherit-
ance is present in some instances. Putnam thinks that possibly both lead
and arsenic play a part in the etiology.
The sy7n2)toms are both sensory and motor. The onset is usually with
numbness in the extremities, progressive loss of strength, and emaciation.
Paraplegia gradually develops, before which there have been, as a rule,
spastic symptoms with exaggerated knee-jerk. The arms are affected less
tlian the legs. Mental symptoms similar to dementia paralytica may de-
velop toward the close.
The diagnosis of this mixed sclerosis rests upon the combination of
sensory and motor symptoms with the presence of exaggerated reflexes.
As stated, the sensory features consist chiefly of paraesthesia, and there
may be difficulty in distinguishing the condition from multiple neuritis.
The frequency of the disease in more or less enfeebled or anaemic women
past middle life is also an important feature.
Treatment of Spastic Paraplegia. — In the majority of cases spas-
tic paraplegia is incurable. The cases which result from transitory com-
pression, as in caries, may get well ; but in the other forms the disease is
uniformly progressive, and remedies have little or no control. AVhen
syphilis is suspected a thorough course of mercury and iodide of potassium
should be given. Scrupulous attention should be paid to the bladder
symptoms, and the same measures may be used as will be advised in loco-
motor ataxia. In the infantile form of paraplegia much may be done by
the orthopaedic surgeon to overcome rigidity and contracture. In several
instances I have known persistent friction with forcible flexion and exten-
sion and the application of proper apparatus enable a patient to get about
comfortably.
II. Locomotor Ataxia
(Tabes Dorsalis ; Posterior Spinal Sclerosis).
Definition. — An affection of the nervous system characterized clin-
ically by incoordination, with sensory and trophic disturbances and in-
volvement of the special senses, particularly the eyes. Anatomically there
are found sclerosis of the posterior columns of the cord, foci of degenera-
tion in the basal ganglia, and sometimes chronic degenerative changes in
the cortex cerebri.
CHRONIC AFFECTIONS OF THE SPINAL CORD. 841
Etiology. — It is a wide-spread disease, more frequent in cities than in
the country. The relative proportion may be judged from the fact that
of 1,816 cases in my neurological dispensary in two years there were 25
cases of locomotor ataxia. Males are attacked more frequently than fe-
males, the proportion being at least ten to one. Mitchell has called at-
tention to the fact that it is a rare disease in the negro. Of 25 cases at
my clinic, 3 were in negroes. It is a disease of adult life, a majority of
the cases occurring between the thirtieth and fortieth years. Occasionally
cases are seen in young men. The form of ataxia which occurs in chil-
dren is a different disease. Of si)ecial causes syphilis is the most impor-
tant. According to the figures of Erb, Fournier, and Gowers, in from fifty
to seventy-five per cent of all cases there is a history of this disease. Erb's
recent figures are most striking ; of 300 cases of tabes in private practice
89 per cent had had syphilis.
Excessive fatigue, overexertion, exposure to cold and wet, and sexual
excesses are all assigned as causes. There are instances in which the dis-
ease has closely followed severe exposure. James Stewart has noted that
the Ottawa lumbermen, who live a very hard life in the camps during the
winter months, are frequently the subjects of locomotor ataxia. Trauma
has been noted in a few cases. Alcoholic excess does not seem to predis-
pose to the disease. Among patients in the better classes of life I do not
remember one in which there had been a previous history of prolonged
drunkenness.
Morbid Anatomy. — When a patient has died in the advanced stage
of the disease the following are the most important changes :
(a) The peripheral nerves may show signs of degeneration. Keuritis
may indeed be present even when there have been no special symptoms
indicating it. In other instances there is not only neuritis, but muscular
atrophy.
(b) The posterior roots of the spinal cord are small, gray, and atro-
phic.
(c) The meninges of the posterior and lateral columns are thickened,
more firmly adherent than normally, and the blood-vessels usually show
signs of arterio-sclerosis.
(d) The changes in the spinal cord are as follows : (1) In advanced
cases the posterior columns are uniformly sclerotic and the dorsal and
lumbar regions are most extensively involved. In long-standing cases
there is generally an increase of connective tissue throughout the cord and
there may be degeneration (2) of the ascending antero-lateral tract; (3)
of the direct cerebellar tract ; (4) of the pyramidal tract.
(e) In early cases the course of the anatomical changes may be traced.
The steps in the process are as follows : Tlie posterior root-zone of Char-
cot is first involved, often with the fibres of the posterior root, so that it
has been thought to begin perhaps as a neuritis of these roots within the
vertebral canal. The narrow strip which lies between the pyramidal tract
842 DISEASES OF THE NERVOUS SYSTEM.
and the posterior cornu, known as Lissauer's tract, is early involved, to-
getlier with the nerve-cells of the adjacent Clarke's vesicular column. In
what is known as the pre-ataxic stage these may be the only alterations.
Subsequently the sclerosis extends widely in the postero-external, and
subsequently in the postero-median columns.
(/) The cerebral changes — of less consequence than the spinal — may
consist of (1) sclerosis in the restiform bodies, in the inferior peduncles
of tlie cerebellum, and of certain of the cranial nerves, particularly the
third, the optic, and the auditory ; (2) cortical changes, consisting in some
cases of a diffuse meningo-encephalitis.
Symptoms. — These are best considered under the three stages of pre-
ataxic, ataxic, and paralytic.
Pre-ataxic Stage. — The following are the most characteristic features
ol this period :
Pains ^ usually of a sharp stabbing character; hence the term, light-
ning pains. They last for only a second or two and are most common in
the legs. They may be associated with a hot, burning feeling. Occasion-
ally herpes may develop at the site of the pain. They may occur at irregu-
lar intervals, and are more prone to follow excesses or to come on when the
health is impaired.
Ocular Symptoms. — {a) Ptosis, which may be single or double and is
by no means uncommon either alone or {p) in association with external
strabismus. The first complaint may be of double vision. Occasionally
there may be paralysis of all the external muscles of the eye, producing
ophthalmoplegia externa, (c) Argyll-Robertson pupil, in which, as already
mentioned, there is loss of the iris reflex to light, but contraction during
accommodation. The pupils are usually small — spinal myosis. {d) Op-
tic atrophy. I'his is often an early, or even the first symptom. The loss
of vision progresses, and in a large majority of cases leads to total blind-
ness.
Loss of the Knee- j eric. — This is one of the earliest symptoms, and may
occur years before there is ataxia. Taken alone it is of no moment, as
there are individuals in whom the knee-jerk is absent ; but in connection
with the lightning pains and the ocular symptoms, it is of special impor-
tance. These are the most common symptoms of the pre-ataxic stage, and
may persist for years without the development of incoordination. The
patient may look well and feel well, and be troubled only by occasional
attacks of lightning pains ; or there is persistent ptosis, external strabis-
mus develops, or, what is more serious, a progressive atrophy of the optic
nerve. There is often a gradual loss of sexual power.
The disease may never progress beyond this stage, and when optic
atrophy develops early and leads to blindness, the ataxia rarely, if ever,
supervenes. There is a sort of antagonism between the ocular symptoms
and tlie progress of the ataxia. Cliarcot lays considerable stress upon this,
and Dejerine assured me that of the enormous tabetic material at the
CHRONIC AFFECTIONS OF THE SPINAL CORD. 843
Bicetre in not a single instance in which optic atrophy had come on early
and progressed to blindness was the patient ataxic, althougli there were
cases which had had the lightning pains and lesions of the optic nerves for
twenty-five years.
Ataxic Stage. — Motor Symptoms.— T\\q ataxia develops gradually.
One of the first indications to the patient is inability to get about readily
in the dark or to maintain his equilibrium when washing his face with
the eyes shut. AVhen the patient stands with the feet together and the
eyes closed, he sways and has difficulty in maintaining his position. This
is known as Romberg symptom. On turning quickly he is apt to fall.
Gradually the characteristic ataxic gait develops. The patient, as a rule,
walks with a stick, the eyes are directed to the ground, the body is thrown
forward, and the legs are wide apart. In walking, the leg is thrown out
violently, the foot is raised too high and is brought down in a stamping
manner with the heel first, or the whole sole comes in contact with the
ground. Ultimately the patient may be unable to walk without the assist-
ance of two canes. This gait is very characteristic, and unlike that seen
in any other disease. The incoordination is not only in walking, but in
the performance of other movements. If the patient is asked, when in
the recumbent posture, to touch the knee with one foot, the irregularity in
the movement is very evident. Incoordination of the arms is less com-
mon, but usually develops in some grade. It may in rare instances exist
before the incoordination of the legs. In the large number of ataxics
which frequented the Infirmary for Xervous Diseases at Philadelphia,
there was only one, so far as I remember — at Weir Mitchell's clinic — in
which the arms were first affected. It may be tested by asking the patient
to close his eyes and to touch the tip of the nose or the tip of the ear with
the finger, or with the arms thrust out to bring the tips of the fingers
together. The incoordination may early be noticed by a difficulty which
the patient experiences in buttoning his collar or in performing one of
the ordinary routine acts of dressing.
One of the most striking features of the disease is that with marked
incoordination there is no loss of muscular power. The grip of the hands
may be strong and firm, the power of the legs, tested by trying to flex
them, may be unimpaired, and their nutrition, except toward the close,
may be unaffected.
Sensory Symptoms. — The lightning pains may persist. They vary
greatly in different cases. Some patients are rendered miserable by the
frequent occurrence of the attacks ; others escape altogether. In addition,
common symptoms are tingling, pins and needles, particularly in the feet,
and areas of hypera^sthesia or of anaesthesia. The patient may complain
of a change in the sensation in the soles of the feet, as if cotton was inter-
posed between the floor and the skin. Sensory disturbances occur less
frequently in the hands. Ketardation of tactile sensation is common, and
a pin-prick on the foot, instead of being instantaneously felt, is not per-
844 DISExVSES OF THE NERVOUS SYSTEM.
ceived for a second or two or may be delayed for as much as ten seconds.
The pain felt may persist. A curious phenomenon is the loss of the power
of localizing the pain. For instance, if the patient is pricked on one limb
he may say that he feels it on the other (allocheiria), or a pin-prick on the
foot may be felt in both feet. The muscular sense becomes much im-
paired and the patient no longer recognizes the position in which his limbs
are placed. This may be present in the pre-ataxic stage.
Reflexes. — As mentioned, the loss of the knee-jerk is one of the earliest
symptoms of the disease. Occasionally a case is found in which it is re-
tained. The skin reflexes may at first be increased, but later are usually
involved with the deep reflexes.
Special Senses. — The eye symptoms noted above may be present, but,
as mentioned, ataxia is rare with atrophy of the optic nerve.
Deafness may develop, due to lesion of the auditory nerve. There may
also be attacks of vertigo. Olfactory symptoms are rare.
Visceral Sym2)toms. — Among the most remarkable sensory disturbances
are the tabetic crises, severe paroxysms of pain referred to various viscera ;
thus laryngeal, gastric, nephralgic, rectal, urethral, and clitoral crises have
been described. The most common are the gastric and laryngeal. In the
former there are intense pains in the stomach, vomiting, and a secretion
of hyperacid gastric juice. The attack may last for several days or even
longer. There may be severe pain without any vomiting. The attacks
are of variable intensity and usually require morphia. Paroxysms of rectal
pain and tenesmus are described. They have not been common in my
experience. Laryngeal crises also are rare. There may be true spasm
with dyspnoea and noisy inspiration. In one instance at least the patient
has died in the attack.
The sphincters are frequently involved. Early in the disease there
may be a retardation or hesitancy in making water. Later there is reten-
tion, and cystitis may occur. L^nless great care is taken the inflammation
may extend to the kidneys. Constipation is extremely common. Late in
the disease the sphincter ani is weakened. The sexual power is usually
lost in the ataxic stage.
Trophic Changes. — Skin rashes may develop in the course of the light-
ning pains, such as herpes, oedema, or local sweating. Alteration in the
nails may occur. A perforating ulcer may develop on the foot, usually
beneath the great toe. Onychia may prove very troublesome.
The arthropathies or joint lesions affect chiefly the knees. They are
unquestionably associated with the disease itself, and not necessarily a
result of trauma. The condition, known as Charcot's joint, is anatomic-
ally similar to that of chronic arthritis deformans. The effusion may be
rapid and there may be great disintegration and destruction of the carti-
lages and bones, leading to dislocation and deformity. Pus was present
in a well-marked Charcot's joint in a patient of C. K. Mills at the Phila-
delphia Hospital. Spontaneous fractures may occur. Among other trophic
CHRONIC AFFECTIONS OF THE SPINAL CORD. 845
disturbances may be mentioned atrophy of the muscles, which is usually a
late manifestation, but may be localized and associated with neuritis. In
any very large collection of cases many instances of atrophy are found, due
either to involvement of the anterior horns or to peripheral neuritis.
Cerebral Si/f/iptoins. — Hemiplegia may develop at any stage of the
disease, more commonly when it is well advanced. It may be due to
ha^morrhagic softening in consequence of disease of the vessels or to pro-
gressive cortical changes. Hemianaesthesia is sometimes present. Very
rarely the hemiplegia is due to coarse syphilitic disease.
Dementia paralytica frequently exists with tabes, and it may be ex-
tremely difficult to determine which has been the primary affection. In
a majority of the cases the locomotor ataxia has preceded the symptoms
of general paresis. In other instances melancholia, dementia, or paranoia
develop.
(c) Paralytic Stage. — After persisting for an indefinite number of
years the j^atient gradually loses the joower of walking and becomes bed-
ridden or paralyzed. In this condition he is very likely to be carried off
by some intercurrent affection, such as pyelo-nephritis, pneumonia, or
tuberculosis.
The Course of the Disease. — A patient may remain in the pre-ataxic
stage for an indefinite period, and the loss of knee-jerk and the gray
atrophy of the optic nerves may be the sole indications of the true nature
of the disease. In such cases incoordination rarely develops. In a ma-
jority of cases the progress is slow, and after six or eight years, sometimes
less, the ataxia is well developed. The symptoms may vary a good deal ;
thus the pains, which may have been excessive at first, often lessen. The
disease may remain stationary for years ; then exacerbations occur and it
makes rapid progress. Occasionally the disease seems to be arrested.
There are instances of what may be called acute ataxia, in which, within
a year or even less, the incoordination is marked, and the paralytic stage
may develop within a few months. The disease itself rarely causes deatli,
and after becoming bedridden the patient may live for fifteen or twenty
years.
Diagnosis. — In the pre-ataxic stage the combination of lightning
pains and the absence of knee-jerk is distinctive. The association of pro-
gressive atrophy of the optic nerves with loss of knee-jerk is also charac-
teristic. The early ocular palsies are of the greatest importance. A squint,
ptosis, or the Argyll-Robertson pupil may be the first symptom, and may
exist with the loss only of the knee-jerk. Loss of the knee-jerk alone,
however, does occasionally occur in healthy individuals.
The diseases most likely to be confounded with locomotor ataxia are:
(1) Peripheral Neuritis. — The pseudo-tabetic gait of arsenical, alcoholic,
or diabetic paralysis is quite unlike that of locomotor ataxia. In these
f«jrms there is a paralysis of the feet and the leg is lifted high in order
that the toes may clear the floor. The use of the word tabes in this con-
846 DISEASES OF THE NERVOUS SYSTEM.
nection should no longer be continued. If in any doubt, the absence of
the lightning pains and eye symptoms and the history will suffice in the
majority of cases to make the diagnosis clear. In diphtheritic paralysis
the early loss of knee-jerk and the associated eye symptoms may suggest
tabes, but the history, the existence of paralysis of the throat, and the
absence of pains render a diagnosis easy.
(2) Ataxic Paraplegia. — Marked incoordination with spastic paralysis
is characteristic of the condition which Gowers has termed ataxic para-
plegia. In a majority of the cases this affection is distinguished also by
the absence of pains and of eye symptoms.
(3) Cerebellar Disease. — The cerebellar incoordination has only a super-
ficial resemblance to that of locomotor ataxia; the knee-jerk is present,
there are no lightning pains, no sensory disturbances ; while, on the other
hand, there are headache, optic neuritis, and vomiting.
(4) Some acute affectiojis involving the posterior columns of the cord
may be followed by incoordination and resemble tabes very closely. In a
case recently under my care, the gait was characteristic and Romberg's
symptom was present. The knee-jerk, however, was retained and there
were no ocular symptoms. The condition had developed within three or
four months, and there was a well-marked history of syphilis. Lender
large doses of iodide of potassium the ataxia and other symptoms com-
pletely disappeared.
(5) General Paresis. — In some cases this offers a serious difficulty. In
the first place, in general paresis, tabetic symptoms often develop ; on the
other hand, there are cases of locomotor ataxia in which, toward the end,
there are symptoms of general paresis. Cases of unusually acute ataxia
with mental symptoms belong, as a rule, to the former disease. The ques-
tion will be considered under general paresis.
(G) Visceral crises and neuralgic symptoms may lead to error, and in
middle-aged men with severe, recurring attacks of gastralgia it is always
well to bear in mind the possibility of tabes, and to make a careful exam-
ination of the eyes and of the knee-jerk.
I^rognosis. — Complete recovery cannot be expected, but arrest of the
progress is not uncommon and a marked amelioration of the symptoms is
frequent. Optic-nerve atrophy, one of the most serious events in the dis-
ease, has this hopeful aspect — that incoordination rarely follows and the
progress may be arrested. Tlie optic atrophy itself is occasionally checked.
On the whole, the prognosis in tabes is bad. The experience of such men
as AYeir Mitchell, Charcot, and Gowers is distinctly opposed to the belief
that locomotor ataxia is ever completely cured.* No such instance has
come under my personal observation.
Treatment. — To arrest the progress and to relieve, if possible, the
symptoms are the objects which tlie practitioner should have in view. A
*For a study of the reputed cures, see L. C. Gray, N. Y. Medical Journal, Nov., 1889.
CHRONIC AFFECTIONS OF THE SPINAL CORD. 847
quiet, well-regulated method of life is essential. It is not well, as a rule,
for a patient to give up his occupation so long as he is able to keep about
and perform ordinary work. I know tabetics who have for years conducted
large businesses, and there have been several notable instances in our pro-
fession of men who have risen to distinction in spite of the existence of this
disease. Excesses of all sorts, more particularly in haccho et venere, should
be carefully avoided. A man in the pre-ataxic stage should not marry.
Care should be taken in the diet, particularly if gastric crises have oc-
curred. To secure arrest of the disease many remedies have been em-
ployed. Although syphilis plays such an important role in the etiology,
it is universally acknowledged that neither mercury nor the iodide of po-
tassium have as a rule the slightest influence over the tabetic lesions. To
this there is but one exception — when the syphilis is comparatively recent ;
when the symptoms develop within two years of the primary infection,
there is then a possibility of arrest by mercury and iodide of potassium.
However, they do not always relieve. In two cases of very rapidly pro-
gressing tabes following syphilis this medication was of no avail. ]S[ot
only is an anti-mercurial treatment of no benefit m the majority of cases
of locomotor ataxia, but my experience tallies with that of Gowers in that
it may even hasten the progress of the disease. Of remedies which may
be tried and are believed by some writers to retard the progress, the fol-
lowing are recommended : Arsenic in full doses, nitrate of silver in quarter-
grain doses. Calabar bean, ergot, and the preparations of gold.
The treatment by suspension introduced a few years ago has already
been practically abandoned. Good effects certainly have followed ni a few
cases, but it was unreasonable from the outset, either on therapeutic or
scientific grounds, to hope that by such a measure permanent changes could
be induced in the pathological condition. The benefits were due in great
part to suggestion and to psychical effects. In any case it must be used
with caution.
For the pains, complete rest in bed, as advised by Weir Mitchell, and
counter-irritation to the spine (either blisters or the thermo-cautery) may
be employed. The severe spells which come on particularly after excesses
of any kind are often promptly relieved by a hot bath or by a Turkish bath.
A prolonged course of nitrate of silver seems in some cases to allay the
pains and lessen the liability to the attacks. I have never seen ill effects
from its use in the spinal scleroses. Antipyrin and antifebrin may be em-
ployed, and occasionally do good, but their analgesic powers in this disease
have been greatly overrated. Cannabis indica is sometimes useful. In
the severe paroxysms of pain hypodermics of morphia or of cocaine
must be used. The use of morphia should be postponed as long as possi-
ble. Electricity is of very little benefit. For the severe attacks of gas-
tralgia, morphia is also required. The laryngeal crises are rarely danger-
ous. An a})plication of cocaine may be made during the spasm, or a few
whiffs of chloroform may be given, or nitrite of amyl. In all cases of tabes
8i8 DISEASES OF THE NERVOUS SYSTEM.
with increased arterial tension the prolonged use of nitroglycerin, given
in increasing doses until the physiological effect is produced, is of great
service in allaying the neuralgic pains and diminishing the frequency of
the crises. Its use must be guarded when there is aortic insufficiency.
The special indication is increased tension. The bladder symptoms de-
mand constant care. When the organ cannot be perfectly emptied the
catheter should be used, and the patient may be taught its use and how
to keep it thoroughly sterilized.
III. Hereditary Ataxia {Friedreich's Ataxia).
In 1861 Friedreich reported six cases of a form of hereditary ataxia,
and the affection has usually gone by his name. Unfortunately, paramyo-
clonus multiplex is also called Friedreich's disease ; so it is best, if his name
is used in connection with this affection, to term it Friedreich's ataxia. It
is a very different disease in many respects from ordinary tabes. It may
or may not be hereditary. It is really a family disease, several brothers
and sisters being, as a rule, affected. The 143 cases analyzed by Griffith
occurred in 71 unrelated families. In his series inheritance of the disease
itself occurred in only 33 cases. Various influences in the parents have
been noted ; alcoholism in only 7 cases. Syphilis has rarely been present.
Of the 143 cases, 86 were males and 57 females. The disease sets in
early in life, and in Griffith's series 15 occurred before the age of two
years, 39 before the sixth year, 45 between the sixth and tenth years, 20
between the eleventh and fifteenth years, 18 between the sixteenth and
twentieth years, and 5 between the twentieth and twenty-fifth years.
The morlid anatomy shows an extensive sclerosis of the posterior
and lateral columns of the spinal cord. The periphery, and the cere-
bellar tracts are usually involved. The recent observations of Dejerine
and Letulle are of special interest, since they seem to indicate that the
change in this disease is a neurogliar (ectodermal) sclerosis, differing en-
tirely from the ordinary spinal sclerosis. According to this view, Fried-
reich's disease is a gliosis of the posterior columns due to developmental
errors.
Symptoms. — The ataxia is unlike the ordinary form. The inco-
ordination begins in the legs, but the gait is peculiar. It is swaying,
irregular, and more like that of a drunken man. There is not the char-
acteristic stamping gait of the true tabes. Romberg's symptom may or
may not be present. The ataxia of the arms occurs early and is very
marked ; the movements are almost choreiform, irregular, and somewhat
swaying. In making any voluntary movement the action is overdone,
the prehension is claw-like, and the fingers may be spread or overex-
tended just before grasping an object. The hand frequently moves about
an object for a moment and then suddenly pounces upon it. There are
irregular, swaying movements, some of which are choreiform, of the head
CHRONIC AFFECTIONS OF THE SPINAL CORD. 849
and shoulders. Tliere is present in many cases what is known as static
ataxia, that is to say, ataxia of quiet action — irregular, slow movements of
the fingers or the hands while at rest.
Sensory symptoms are not usually present. The reflexes may be lost.
In Griffith's table they were abolished in 91 cases.
Nystagmus is a characteristic symptom. Atrophy of the optic nerve
rarely occurs. A striking feature is early deformity of the feet. There
is talipes equinus, and the patient walks on the outer edge of the feet.
The big toe is flexed dorsally on the first phalanx. Lateral curvature of
the spine is very common.
Trophic lesions are rare. As the disease advances paralysis comes on
and may ultimately be complete. Some of the patients never walk.
Disturbance of speech is common. It is usually slow and scanning ;
the expression is often dull ; the mental power is, as a rule, maintained,
but late in the disease becomes impaired.
The diagnosis of the disease is not difficult when several members of
a family are affected. The onset in childhood, the curious form of inco-
ordination, the early talipes equinus, the position of the great toe, the
scoliosis, the nystagmus, and scanning speech make up an unmistakable
picture. The disease is often confounded with chorea, Avith the ordinary
form of which it has nothing in common. With hereditary chorea it has
certain similarities, but usually this disease does not set in until after the
thirtieth year.
The disease lasts for many years and is incurable. Care should be
taken to prevent contractures.
IV. Syrikgo-myelia.
Definition. — A gliomatous new formation about the central canal of
the spinal cord, with cavity formation.
The disease has attracted a good deal of attention within the past few
years, and has a definite clinical interest since cases can now be diag-
nosed.
Etiology and Morbid Anatomy. — Syringo-myelia must be dis-
tinguished from dilatation of the central canal — hydromyelus — slight grades
of which are not very uncommon either as a congenital condition or as a
result of the pressure of tumors. The cavity of syringo-myelia has a vari-
able extent in the cord, sometimes existing in the entire length, but in
many cases involving only the cervical and dorsal regions or a more limited
area. It is usually in the posterior portion of the cord and extends into
one posterior cornu. The transverse section may be oval or circular or
narrow and fissure-like. It varies at different levels. The condition is
now regarded as a gliosis^ a development of embryonal neurogliar tissue
in which haomorrhage or degeneration takes place with the formation of
cavities.
850 DISEASES OF THE NERVOUS SYSTEM.
Symptoms. — The disease, which is of slow development, makes its
appearance, as a rule, about adolescence, and may persist for fifteen or
twenty years. There are irregular pains, chiefly in the cervical region ;
muscular atrophy develops, which may be confined to the arms, or some-
times extends to the legs. The reflexes are increased and a spastic condi-
tion develops in the legs. Ultimately the clinical picture may be that of
an amyotrophic lateral sclerosis. The tactile sensation is usually intact
and the muscular sense is retained, but painful and thermic sensations are
not recognized, or there may be in rare instances complete anaesthesia of
the skin and of the mucous membranes (Dejerine). This combination of
loss of painful and thermic sensations with paralysis of an amyotrophic
type is regarded as pathognomonic of the disease. The special senses are
usually intact and the sphincters uninvolved. Trophic troubles are not
uncommon. Owing to the loss of the painful and heat sensations, the
patients are apt to injure themselves. A man aged seventy, whom I saw
with Dejerine at the Bicetre, had had the symptoms for over twenty-five
years. Loss of sensation had preceded the atrophy, and the terminal
phalanx of the middle finger was charred, as he experienced no sensation
whatever when the hot end of the cigarette neared his finger. Scoliosis
also may be present in these cases. The loss of painful and thermic im-
pressions is due to the fact that these pass to the brain in the peri-ependy-
mal gray matter, particularly that portion in the posterior roots, which is
almost constantly involved in syringo-myelia. The tactile sensation is re-
tained because the postero-external column is uninvolved.
In typical cases the diagnosis is easy. The combination of an amyotro-
phic paralysis, the picture of progressive muscular atrophy of the Aran-
Duchenne type, with retention of tactile and loss of thermic and painful
sensation, is probably pathognomonic of the disease. Of affections with
which it may be confounded, anaesthetic leprosy is the most important,
since the anaesthesia and the wasting may closely simulate it ; but, as a rule,
in leprosy trophic changes are more or less marked. There is often loss of
phalanges and there is no characteristic dissociation of sensory impressions.
There is a remarkable affection confined to a district of Brittany and
known as Morvan's disease, after the physician who described it. The
disease is chronic and characterized by neuralgic pains, cutaneous anass-
thesia, and painless and destructive whitlows. In Gombault's autopsy
neuritis was found, but it could not be decided, owing to the state of the cord
wlien examined, whether cavities existed or not. Joffroy reports a case in
which syringo-myelia was present and claims the affections are identical.
The curious distribution of the disease and the fact that at least 20 cases
have occurred in a population of 5,000, suggest that it is possibly a periph-
eral neuritis of infectious origin. Church, of Chicago, has reported
case in which, with features believed to be characteristic of syringo-myelia,
the patient had the painless and destructive whitlows which form so special
a feature in Morvan's disease.
CHRONIC AFFECTIONS OF THE SPINAL CORD. 851
V. Compression of the Spinal Cord {Comjnession Myelitis).
Definition. — Interruption of the functions of the cord by slow com-
pression.
Etiology. — Caries of the spine, new growths, aneurism, and para-
sites are tlie important causes of slow compression. Caries, or Pott's dis-
ease, as it is usually called, after the surgeon who first described it, is in
the great majority of instances a tuberculous affection. In a few cases it
is due to syphilis and occasionally to extension of disease from the phar-
ynx. It is most common in early life, but may occur after middle age.
It follows trauma in a few cases. Compression occasionally results from
aneurism of the thoracic aorta or the abdominal aorta, in the neighborhood
of the coeliac axis.
Malignant growths frequently cause a compression paraplegia. A
retroperitoneal sarcoma or the lymphadenomatous growths of Hodgkin's
disease may invade the vertebra?. More commonly, however, the involve-
ment is secondary to scirrhus of the breast.
Of parasites, the echinococcus and the cysticercus occasionally occur
in the spinal canal.
Symptoms. — These may be considered as they affect the bones, the
nerves, and the cord.
(1) Vertebral. — In malignant disease and in aneurism erosion of the
bodies may take place without producing any deformity of the spine. In
caries, on the other hand, it is the rule to find more or less deformity,
amounting often to angular curvature. The compression is largely due to
the thickening of the dura and the presence of caseous and inflammatory
products between this membrane and the bone. The compression is rare-
ly produced directly by the bone. Pain is a constant and, in the case of
aneurism and tumor, agonizing feature. In caries, the spinal processes of
the affected vertebrae are tender on pressure, and pain follows jarring
movements or twisting of the spine. There may be extensive tuberculous
disease without much deformity, particularly in the cervical region.
(2) Nerve-root Symptoms. — These result from compression of the
nerve-roots as they pass out between the vertebrae. It is remarkable how
frequently, even in extensive caries, they escape and the patient does not
complain of radiating pains in the distribution of the nerves from the
affected segment. Pains are more common in cancer of the spine second-
ary to that of the breast, and in such cases may be agonizing. There may
be acutely painful areas of hyperaesthesia of the skin or anaesthesia — the
anwsthesia doloroHci. Trophic disturbances may occur, particularly herpes.
In the cervical or lumbar regions pressure on the anterior roots may give
rise to wasting of the muscles supplied by the affected nerves.
(3) Cord Symptoms. («) Cervical Region. — Not infrequently the
caries is high up between the axis and the atlas or between the latter and
the occipital bone. In such instances a retropharyngeal abscess may be
54
852 DISEASES OF THE NERVOUS SYSTEM.
present, giving rise to difficulty in swallowing. There may be spasm of
the cervical muscles, the head may be fixed, and movements may either
be impossible or cause great pain. In a case of this kind in the Montreal
General Hospital movement was liable to be followed by transient, instan-
taneous paralysis of all four extremities, owing to compression of the cord.
In one of these attacks the patient died.
In the lower cervical region there may be signs of interference with
the cilio-spinal centre and dilatation of the pupils. Occasionally there is
flushing of the face and ear of one side or unilateral sweating. Deform-
ity is not so common, but healing may take place with the production of
a callus of enormous breadth, and complete rigidity of the neck. The
nerves of the upper extremities may be involved, and shooting pains may
occur in the arm.
(b) Dorsal Region. — The deformity is here more marked and pressure
symptoms are more common. The time of onset of the paralysis varies
very much. It may be an early symptom, even before the curvature is
manifest. More commonly it is late, occurring many months after the
curvature has developed. The paraplegia is slow in its development ; the
patient at first feels weak in the legs or has disturbance of sensation,
numbness, tingling, pins and needles. The girdle sensation may be
marked, or severe pains in the course of the intercostal nerves. Motion
is, as a rule, more quickly lost than sensation. Finally, there is complete
interruption with the production of paraplegia, usually of the spastic type,
with exaggeration of the reflexes. This may persist for months, or even
for more than a year, and recovery still be possible.
(c) Lumhar Region. — In the lower dorsal and lumbar regions the
symptoms are practically the same, but the sphincter centres are involved
and the reflexes are not exaggerated.
Diagnosis. — Caries is by far the most frequent cause of slow com-
pression of the cord, and when there are external signs the recognition is
easy. There are cases in w^hich the exudation in the spinal canal between
the dura and the bone leads to compression before there are any signs of
caries, and if the root symptoms are absent it may be extremely difficult
to arrive at a diagnosis. Janeway has called attention to persistent lum-
bago as a symptom of importance in masked Pott's disease, particularly
after injury. Brown-Sequard's paralysis is more common in tumor and
in injuries than in caries. Pressure on the nerve-roots, too, is less fre-
quent in caries than in malignant disease. The cervical form of pachy-
meningitis also produces a pressure paralysis, the symptoms of which have
already been detailed. Pressure from cancer is naturally suggested when
spinal symptoms follow within a few years after an operation. In para-
plegia following tumor of the vertebra secondary to cancer of the breast,
and in the erosion of the spine by retroperitoneal growths, the suffering
is most intense. The condition has been well termed paraplegia dolo-
rosa.
CHRONIC AFFECTIONS OF THE SPINAL CORD. 853
Treatment. — In compression by anenrism or tumor the condition is
hopeless. In the former the pains are often not very severe, but in the
latter morpliia is always necessary. On the other hand, compression by
caries is often successfully relieved even after the paralysis has persisted
for a long period. When caries is recognized early, rest and support to
the spine by the various methods now used by surgeons may do much to
prevent the onset of paraplegia. When paralysis has developed, rest with
extension gives the best hope of recovery. It is to be remembered that
restoration may occur after compression of the cord has lasted for many
months, or even more than a year. Cases have been cured by rest alone ;
the extradural and inflammatory products are absorbed and the caries heal.
The most brilliant results in these cases have been obtained by suspension, a
method introduced by J. K. Mitchell in 1826, and pursued with remarkable
success by his son. Weir Mitchell. During my association with the Infirmary
for Nervous Diseases I had numerous opportunities of witnessing the really
remarkable effects of persistent suspension, even in apparently desperate
and protracted cases. Mitchell's conclusions are that suspension should
be employed early in Pott's disease ; that used with care it enables us
slowly to lessen the curve ; that in these cases there must be, in some
form, a replacement of the crumpled tissues ; that unless there is great
loss of power the use of the spine-car or chair of J. K. Mitchell enables
suspension, especially in children, to be combined wdth some exercise ;
that no case of Pott's disease should be considered desperate without its
trial ; that suspension has succeeded after failures of other accepted meth-
ods ; that the pull probably acts mere or less directly on the cord itself,
and that the gain is not explicable merely by obvious effects on the angu-
lar bony curve ; that the methods of extension to be used in carious cases
may be very varied, provided only we get active extension ; that the plan
and the length of time of extension must be made to conform to the
needs, endurance, and sensation of the individual case. It may be months
before there are any signs of improvement. In protracted cases, after
suspension has been tried for months, laminectomy may be considered,
and has in some instances been successful.*
The general treatment of caries is that of tuberculosis — fresh air, good
food, cod-liver oil, and arsenic. Counter-irritation in these instances is
of doubtful value.
Unilateral Lesions of the Spinal Cord (Brown-Sequard's Paralysis).—
Tumors, stab wounds, and less frequently fracture or caries, may destroy
one half of the cord, causing a peculiar and definite palsy, which was first
recognized by Brown-Sequard, after whom it has been named. In a uni-
lateral lesion the motor fibres are interrupted after their decussation in
the medulla, consequently there is paralysis of the leg, or, if the lesion is
in the cervical cord, of the arm and leg on the same side — spinal hemi-
* Sec full discussion of Uio subject by J. William White, Therapeutic Gazette, 1891.
854:
DISEASES OF THE NERVOUS SYSTEM.
plegia. As the sensory fibres, entering the cord through the posterior
roots, decussate at once and ascend in the opposite half of the cord, there
is loss of sensation on the side opposite to the lesion, so that in hemi-
section of the cervical cord above the brachial enlargement there is motor
paralysis of the arm and leg of the same side and anaesthesia of the arm
and leg of the opposite side. The anaesthesia may be only to painful and
to thermic sensation. In many cases the tactile sensation is unimpaired.
The muscular sense is diminished on the same side as the lesion, and on
this side also the skin is hyperaesthetic, so that a slight irritation is felt
very acutely. Of this phenomenon, which may persist for years, no satis-
factory explanation has been given. Just above the level of the hyperaes-
thesia there is a narrow zone of anaesthesia, which is at the exact physio-
logical level of the lesion and corresponds to the fibres coming from the
same side, which are involved at once on entering the cord. Above this
again there is a narrow zone of hyperaesthesia. The reflexes are usually
increased on the side of the lesion and the temperature is slightly raised.
The following table of Gowers illustrates the distribution of these vari-
ous symptoms in a hemi-lesion of the cord :
Cord.
Zone of cutaneous hyperaesthesia.
Zone of cutaneous anaesthesia.
Motor palsy.
Hyperaesthesia of skin.
Muscular sense impaired.
Reflex action first lessened and
then increased.
Temperature raised.
Lesion.
Muscular power normal.
Loss of sensibility of skin.
Muscular sense normal.
Reflex action normal.
Temperature same as that above
lesion.
It is only in exceptional cases that all these features are met with in a
case of Brown-Sequard's paralysis, and the condition may be transitory
and rapidly replaced by paraplegia.
VI. Lesions of the Cauda Equina and Conus Medullaris.
The spinal cord extends only to the second lumbar vertebra. Injury,
tumors, and caries at or below this level involve not the cord itself, but
the bundle of nerves known as the cauda equina and the terminal portion
of the cord, the conns medullaris. Much attention has been given re-
cently to lesions of this part. Tlie whole subject is admirably discussed in a
recent work by Thorburn.* Fractures and dislocations are common in the
lumbo-sacral region, tumors not infrequently involve the filaments of the
Cauda equina, and some of the nerves may be entangled in the cicatrix of
a spina bifida.
♦ A Contribution to the Surgery of the Spinal Cord,
don, 1890.
By William Thorburn. Lon-
CHRONIC AFFECTIONS OF THE SPINAL CORD. 855
In a fracture or dislocation of the first lumbar vertebra the conus mo-
dullaris may be compressed with the last sacral nerves given off from it.
In a case recently reported by Kirchhoff there was laceration of the conus
with complete paralysis of the bladder and rectum, a case which is held to
favor the view that the ano-vesical centre in man is situated in this region
of the cord. There are several instances on record in which injury of the
Cauda equina has produced paralysis of the bladder and rectum alone,
sometimes with a slight patch of anaesthesia in the neighborhood of the
coccyx or the perinaeum. More commonly branches of the sacral or lum-
bar nerve roots are involved producing an irregularly distributed motor
and sensory paralysis in the legs. When the lumbar nerve-roots from the
second to the fifth are compressed there is paralysis of the muscles of the
legs, with the exception of the flexors of the ankles, the peronaei, the long
flexors of the toes, and the intrinsic muscles of the feet, and loss of sensa-
tion in the front, inner, and outer part of the thighs, the inner side of the
legs, and the inner side of the foot. The sacral roots may alone be in-
volved. Thus in a case which I have reported the patient fell from a bridge
and had paralysis of the legs and of the bladder and rectum. When seen
sixteen years after the injury, there was slight weakness, with wasting of the
left leg ; there was complete loss of the function in the ano-vesical and gen-
ital centres, and anaesthesia in a strip at the back part of the thigh (in the
distribution of the small sciatic), and of the perinaeum, scrotum, and
penis. The urethra was also insensitive. In a second case, in a young
man with a healed spina bifida there was, with a small area of anaesthesia,
involvement of the bladder and rectum, but retention of the sexual
power.
Starr's table, given in the section on motor localization, will be found
useful in determining the nerve fibres and segments involved in these cases
of injury of the cauda equina.
VII. Tumors of the Spinal Cord axd its Membranes.
New growths may develop in the cord or in its membranes, or may
extend into them from the spine. The first two alone will be considered.
Occasionally lipoma and parasites occur in the extradural space. Within
the dura fibromata, sarcomata, and syphilitic and tuberculous growths are
most common. In the cord itself, and attached to the pia mater, the
tuberculous, syphilitic, and gliomatous growths are most frequent. Of
50 cases of tumor of the spinal cord and its envelopes analyzed by Mills
and Lloyd, only 3 were parasitic. Of these 26 were some form of neo-
plasm, of which sarcomata were most common, 5 were gummatous, and 4
tuberculous. Ilerter has recently reported 3 cases of solitary tubercle in
the cord, and has analyzed others from the literature. Of 24 cases in
which the age was given, 15 occurred between the ages of fifteen and
thirty-five, and 5 before the fifth year. Tlie tumor is most common in
856 DISEASES OF THE NERVOUS SYSTEM.
the dorsal and lumbar regions, and is usually met with in connection with
tuberculous lesions elsewhere.
The anatomical effects of tumors are very varied. Slow compression
is usually produced by growths external to the cord, and it is remarkable
what a high grade of compression the cord will bear without serious inter-
ference with its functions. In cases of prolonged interruption ascending
and descending degenerations occur. Tumors developing within the cord
may lead to syringo-myelia. And, lastly, tumors not infrequently excite
intense myelitis.
Symptoms. — These will naturally vary a good deal with the segment
involved and with the degree of pressure and the extent of implication of
the nerve-roots.
Within the cord the symptoms are those of a gradually progressing
paraplegia, which may at first have the picture of a Brown-Sequard paral-
ysis. Atrophy follows the involvement of the anterior cornua, and vaso-
motor disturbances may be marked. The reflexes are lost at the level of
the lesion, but if in the dorsal cord, the reflexes are retained in the legs.
The symptoms are aj^t to be complicated with those of acute or subacute
myelitis, which may completely alter the clinical picture. Tumors of the
spinal membranes are characterized by the early onset and persistence of
the root symptoms, which consist of radiating pains, girdle sensation,
hypersesthesia, or anaesthesia in various portions of the trunk. There may
even be severe pain in the anaesthetic areas. Irritation' of the motor roots
may cause spasm of the muscles supplied, or wasting with paralysis. The
paraplegia supervenes some time after the occurrence of the root symp-
toms. In the dorsal region the level of the growth is usually accurately
defined by the level of the pain and the condition of the reflexes.
The diagnosis of tumor within the cord is sometimes easy, the charac-
teristic features being the constancy and severity of the root symptoms at
the level of the growth and the progressive paralysis. Caries may cause
identical symptoms, but the radiating pains are rarely so severe. Cervical
meningitis simulates tumor very closely, and in reality produces identical
effects, but the very slow progress and the bilateral character from the
outset may be sufficient to distinguish this.
In chronic transverse myelitis the symptoms may, according to Gow-
ers, simulate tumor very closely and present radiating pains, a sense of
constriction, and progressive paralysis.
The nature of the tumor can rarely be indicated with precision. With
a marked syphilitic history gumma may naturally be suspected, and with
coexisting tuberculous disease a solitary tubercle.
Treatm.ent. — If the possibility of syphilitic infection is present the
iodide of potassium should be given in large and increasing doses. For
the severe pains counter-irritation is sometimes beneficial, particularly the
thermo-cautery ; morphia is, however, often necessary.
In a few instances tumors of tlie cord or of the membranes are amena-
CHRONIC AFFP]CTIONS OP THE SPINAL (JORD. 857
ble to surgical treatment. The removal by Victor Ilorsley of a growth
from the membranes of the cord in a patient of Gowers' wa-5 one of tlie
most brilliant operations of modern surgery.
VIII. Progressive (Spinal) Muscular Atrophy
{Chronic Degeneration of the Motor Nuclei — Polioinyelitls Anterior
Chronica).
Definition. — A disease characterized by degeneration of groups of
the motor nuclei in the cord and medulla, with wasting of the correspond-
ing muscles. The pyramidal tracts are usually involved, and the paralysis
may have a spastic character. In some cases the degeneration has been
traced to the ganglion cells of the motor cortex.
Three affections, as a rule described apart, belong together in this
category : [a) Progressive muscular atrophy of spinal origin ; {b) amyo-
trophic lateral sclerosis ; and (c) progressive bulbar paralysis. A slow
atrophic change in the motor nuclei is the anatomical basis, and the dis-
ease, as Charcot states, is one of the whole motor path, involving, in many
cases, the cortical, bulbar, and spinal centres. There may be simple mus-
cular atrophy with little or no spasm, or progressive wasting with marked
spasm and great increase in the reflexes. In others, there are added symp-
toms of involvement of the motor nuclei in the medulla — a glosso-labio-
laryngeal paralysis ; while in others, again, with atrophy (especially of the
arms), a spastic condition of the legs, and bulbar phenomena, tremors
develop and signs of cortical lesion. These various stages may be traced
in the same case. I have for ten years had under observation a man whose
illness began with weakness and atrophy of the hand muscles. Gradually
the legs began to get stiff and the gait spastic ; the arms subsequently
wasted and the reflexes were increased. After these symj)toms had per-
sisted with increasing intensity for six or seven years, certain of the
motor nuclei of the medulla became involved, the speech became thick,
and the movements of the lips and tongue were impaired. Tremor has
developed of late in the arms and hands. With these chronic changes the
visceral functions have remained unimpaired and the mind unaffected.
It has been a lesion of the motor segments, beginning in the lower and
gradually extending upward. The disease began as progressive atrophy,
and gradually assumed a typical picture of amyotrophic lateral sclerosis,
and now the bulbar features are well marked and the tremor would in-
dicate that the cortex is also involved.
For convenience, bulbar paral3^sis will be considered separately, and I
shall here take up iog(it\\Q,Y progressive muscular atrophy and amyotrophic
lateral sclerosis.
The disease is known as the Aran-Duchenne type of progressive mus-
cular atrophy, after the French physicians who early described it, and as
Cruvcilhier's palsy. Lockhard Clarke demonstrated that it was a spinal
858 DISEASES OF THE NERVOUS SYSTEM.
lesion. Charcot separated the two types — one with simple wasting, in
which the anterior horns are alone involved ; and the other in which, with
degeneration of the cornna, the pyramidal tracts are affected, causing
wasting plus a spastic condition. To this he gave the name of amyotro-
phic lateral sclerosis. There is but little evidence, however, to show that
the anterior horns are ever affected without secondary changes in the
pyramidal tracts, and Leyden and Gowers regard the two diseases as iden-
tical.
Etiology. — The cause of the disease is unknown. It is more frequent
in males than in females. It attacks adults, developing after the thirtieth
year, though occasionally younger persons are attacked. A large majority
of all cases of progressive muscular atrophy under twenty-five years of age
are of myopathic (i. e., muscular), not myelopathic (i. e., spinal) origin.
Cold, wet, exposure, fright, and mental worries are mentioned as possible
causes. Hereditary influences are present in certain cases. The father of
the man whose case is referred to above died of progressive wasting of the
muscles, but there have been no other cases in the family. It is highly
probable that when many members of a family are affected the disease is
not spinal, but an idiopathic muscular atrophy; and yet, in the Farr
family, which I recorded a few years ago, in which thirteen members were
affected in two generations, with the exception of two, the cases occurred
or proved fatal above the age of forty, and the late onset speaks rather
for a spinal affection. The amyotrophic form may develop late in life —
after seventy — as a senile change.
Morbid Anatomy. — The following are the important anatomical
changes : («) The muscles waste and undergo fatty and sclerotic changes.
The terminal branches of the motor nerves are degenerated, (h) The
anterior roots are atrophied in those sections of the cord corresponding to
the wasted muscles, {c) The gray matter shows the most marked altera-
tion. The large ganglion cells of the anterior horns are atrophied, or, in
places, have entirely disappeared, the neurogliar tissue is increased, and
the fibres of the anterior nerve-root passing through the white matter are
wasted, {d) In a majority of all the cases there is sclerosis in the antero-
lateral tracts, but the direct cerebellar and the antero-lateral ascending
tracts are spared. It was to this combination of atrophy of the anterior
horns and sclerosis of the antero-lateral columns that Charcot gave the
name amyotrophic lateral sclerosis, {e) The degeneration of the gray
matter is rarely confined to the cord, but extends to the medulla ; the
motor nuclei are found extensively wasted in cases which have shown
bulbar symptoms during life. (/) Cerebral changes also occur. The
pyramidal tracts have been found degenerated through the pons and cap-
sule, and in the motor cortex the large ganglion cells are wasted.
The essential anatomical change is a slow degeneration of the motor
path, involving specially the nerve-cells of the anterior cornua and the
anterior root-fibres, to which tlie loss of power and wasting in the muscles
CHRONIC AFFECTIONS OF TIIF SPINAL CORD. 859
are secondary. The upper segment is also involved, either simultaneously
or at a later period.
Symptoms. — Irregular pains may precede the onset of the wasting.
In one case the pains were about the hip and slioulder joints and the pa-
tient was treated for chronic rheumatism. The hands are first affected,
and there is difficulty in performing delicate manipulations. The muscles
of the ball of the thumb waste early, then the interossei and lumbricales,
leaving marked depressions between the metacarpal bones. Ultimately the
contraction of the flexor and extensor muscles and the extreme atrophy
of the thumb muscles, the interossei, and lumbricales produces the claw-
hand — main en griffe of Duchenne. The flexors of the forearm are usu-
ally involved before the extensors. In the shoulder-girdle the deltoid
wastes first ; it may waste even before the other muscles of the upper ex-
tremity. The trunk muscles are gradually attacked ; the upper part of
the trapezius long remains unaffected. Owing to the feebleness of the
muscles which support it, the head tends to fall forward. The platysma
myoides is unaffected and often hypertrophies. The arms and the trunk
muscles may be much atrophied before the legs are attacked. The
glutei, the vasti, and the tibialis anticus are first attacked when the dis-
ease begins in the legs. In the member of the Farr family who came
under my notice (if this was really a myelopathic disorder) the wasting
began in the gluteal and hamstring muscles of the left leg. The face
muscles are attacked late. Ultimately the intercostal and abdominal
muscles may be involved, the wasting proceeds to an extreme grade, and
the patient may be actually " skin and bone," and, as " living skeletons,"
the cases are not uncommon in " museums " and " side-shoAVS." Deformi-
ties and contractures result, and lordosis is almost always present. A
curious twitching of the muscles (fibrillation) is a common symptom, and
may occur in muscles which are not yet attacked. It is not, as was for-
merly supposed, a characteristic feature of the disease. The irritability
of the muscle is increased. Sensation is unimpaired, but the patient may
complain of numbness and coldness of the affected limbs. The galvanic
and faradic irritability of the muscles progressively diminishes and may
become extinct, the galvanic persisting for the longest time. In cases of
rapid wasting and paralysis there may be the reaction of degeneration.
The excitability of the nerve-trunks may persist after the muscles have
ceased to respond. The loss of power is usually proportionate to the de-
gree of wasting.
The foregoing description applies to the group of cases in which the
atrophy and paralysis are flaccid — atonic^ as Gowers calls it. In other cases,
those which* Charcot describes as amyotrophic lateral sclerosis, with the
wasting there is more or less spasm, which may exist from the outset.
1'his tonic atrophy may involve the legs chiefly or is present in tlie arms
and legs. Tlie reflexes are greatly increased. . The most typical condition
of spastic paraplegia may be produced. On starting to walk, the patient
860 DISEASES OF THE NERVOUS SYSTEM.
«
seems glued to the ground and makes ineffectual attempts to lift the toes ;
then four or five short, quick steps are taken on the toes with the body
thrown forward ; and finally he starts off, sometimes with great rapidity.
Some of the patients can walk up and down stairs better than on the level.
The wasting is never so extreme as in the atonic form, and the loss of
power may be out of proportion to it. The sphincters are unaffected.
Sexual power may be lost early.
As the degeneration extends upward an important change takes place
from the development of bulbar symptoms, which may, however, precede
the spinal manifestations. The lips, tongue, face, pharynx, and larynx
may be involved. The lips may be affected and articulation impaired for
years before serious symptoms occur. In the final stage there may be
tremor, the memory fails, and a condition of dementia may develop.
Gowers gives the following useful classification of the varieties of this
affection: (1) Atonic atrophy, becoming extreme ; (2) muscular weakness
with spasm, but without wasting or with only slight w^asting; and (3)
atonic atrophy, rarely extreme in degree, with excess of the reflexes.
These conditions may " coexist in every degree and combination — between
universal atonic atrophy on the one hand and universal spastic paralysis
without wasting on the other."
Diagnosis. — The affection must be distinguished from the primary
muscular atrophies which usually occur in younger persons, ofton affect
many members of a family, and have a different distribution, beginning
either in the muscles of the shoulder girdle — sparing the hands or involv-
ing the face and upper-arm muscles — or the peroneal group. Muscular
atrophy in the adult, beginning in the muscles of the thumbs, gradually
involving the interossei and lumbricales, as a rule is of myelopathic origin.
Treatment. — The disease is incurable. I have never seen the
slightest benefit from drugs or electricity. The downward progress is
slow but certain, though in a few cases a temporary arrest may take place.
With a history of syphilis, mercury and iodide of potassium may be tried,
and Gowers recommends courses of arsenic and strychnine. Probably the
most useful means is systematic massage, particularly in the spastic cases.
Bulbar Paralysis {Glosso-lahio-laryngeal Paralysis).
An affection of the motor nuclei of the medulla oblongata, rarely pri-
mary, more commonly a part of a general degenerative affection of the
nuclei of the motor path. The disease is sometimes called by the name of
Duchenne. Acute and chronic forms may be recognized.
(1) Acute bulbar paralysis may be due to {a) hcX^morrhagib or embolic
softening in the pons and medulla; {b) acute inflammatory softening,
analogous to polio-myelitis, occurring occasionally as a post-febrile affec-
tion.
The onset is usually sudden, hence the term apoplectiform. The cases
1
CHRONIC AFFECTIONS OF THE SPINAL CORD. 861
are almost invariably bilateral. As the nuclei presiding over the muscles
of the tongue and lips are involved the speech is almost or entirely lost.
The saliva drools, the lips are flabby and flaccid, swallowing may be diffi-
cult, and there may be loss of power in the laryngeal muscles. Usually
these cases rapidly prove fatal, but occasionally a case with a sudden onset,
like that figured by Gowers, may become chronic. In these acute cases
there may be loss of power in one arm, or hemiplegia, sometimes alternate
hemiplegia, with paralysis on one side of the face and loss of power on the
other side of the body.
(2) Chronic bulbar paralysis is an affection of adult life, rarely begin-
ning under the fortieth year, and in a great majority of the cases it is only
part of a general degeneration of the motor nuclei. The disease usually
begins with slight defect in the speech, and the patient has difficulty in
pronouncing the dentals and Unguals. The paralysis starts in the tongue,
and the superior lingual muscle gradually becomes atrophied, and finally
the mucous membrane is thrown into transverse folds. In the process of
wasting the fibrillary tremors are seen. Owing to the loss of power in the
tongue, the food is with difficulty pushed back into the pharynx. The
saliva also may be increased, and is apt to accumulate in the mouth. When
the lips become involved the patient can neither whistle nor pronounce
the vowels o and u. The mouth looks large, the lips are prominent, and
there is constant drooling. The food is masticated with difficulty. Swal-
lowing becomes difficult, owing partly to the regurgitation into the nos-
trils, partly to the involvement of the pharyngeal muscles. The muscles
of the vocal cords waste and the voice becomes feeble, but the laryngeal
paralysis is rarely so extreme as that of the lips and tongue.
The course of the disease is slow but progressive. Death often results
from an aspiration pneumonia, sometimes from choking, more rarely from
involvement of the respiratory centres. The mind usually remains clear.
The patient may become emotional. In a majority of the cases the dis-
ease is only part of a progressive atrophy, either simple or associated with
a spastic condition. In the latter stage of amyotrophic lateral sclerosis
the bulbar lesions may paralyze the lips long before the pharynx or larynx
becomes affected.
The diagnosis of the disease is readily made, either in the acute or
chronic form. The involvement of the lips and tongue is usually well
marked, while that of the palate may be long deferred. A condition has
been described, however, which may closely simulate bulbar paralysis.
This is the so-called pseudo-bulbar form or bulbar palsy of cerebral origin.
Bilateral disease of the motor cortex in the lower part of the ascending
frontal convolution may cause paralysis of the lips and tongue and pharynx,
which closely simulates a lesion of the medulla. Sometimes the symptoms
appear on one side, but in many instances they develop suddenly on both
sides. A bilateral lesion has usually been found, but in several instances
the disease was unilateral.
8G2 DISEASES OF THE NERVOUS SYSTEM.
Progressive bulbar paralysis is an incurable affection. Transient im-
provement may occur. Strychnine may be tried. Electricity is of doubt-
ful benefit. Special care must be taken in feeding these patients, and
when deglutition becomes much impaired the stomach-tube should be
employed.
III. DISEASES OF THE BRAIX.
I. AFFECTIONS OF THE MENINGES.
Diseases of the Dura Mater {Pachymeningitis).
(a) Pachymeningitis Externa. — Haemorrhage often occurs as a result
of fracture. Inflammation of the external layer of the dura is rare.
Caries of the bone, either extension from middle-ear disease or due to
syphilis, is the principal cause. In the syphilitic cases there may be a
great thickening of the inner table and a large collection of pus between
the dura and the bone. In a remarkable case of this kind at the Mont-
real General Hospital the frontal lobes were so compressed by the
thickened skull, and the purulent effusion between the bone and the dura,
that the anterior vertical measurement of the brain was only 2*5 cm., while
that of the posterior part was 8 cm.
Occasionally the pus is infiltrated between the two layers of the dura
mater or may extend through and cause a dura-arachnitis.
The symptoms of external pachymeningitis are indefinite. In the
syphilitic cases there may be a small sinus communicating with the ex-
terior. Compression symptoms may occur with or without paralysis.
(b) Pachymeningitis Interna. — This occurs in three forms : (1) Pseudo-
membranous, (2) purulent, and (3) haemorrhagic. The first two are un-
important. Pseudo-membranous inflammation of the lining membrane
of the dura is not usually recognized, but a most characteristic example
of it came under my observation as a secondary process in pneumonia.
Purulent pachymeningitis may follow an injury, but is more commonly
the result of extension from inflammation of the pia. It is remarkable
how rarely pus is found between the dura and arachnoid membranes.
H/EMORRHAGic PACHYMENINGITIS {Ilceiuatoma of the Dura Mater).
This remarkable condition, first described by Virchow, is very rare in
general medical practice. During ten years no instance of it came under
my observation at the Montreal General Hospital. On the other hand,
in the post-mortem room of the Philadelphia Hospital, which received
material from a large almshouse and asylum, the cases were not uncom-
mon, and witliin three months I saw four characteristic examples, three
of which came from the medical wards. On the other hand, the frequency
AFFECTIONS OF THE MENINGES. 8G3
of the condition in asylum work may be gathered from the fact that Wig-
glesworth found 42 examples in a series of 400 unselected post-mortem
examinations.
The disease is found chiefly in males and in persons over fifty years of
age. It is most frequent in forms of chronic insanity and in chronic
alcoholism. It has also been found in profound anaemia and other blood
conditions, and is said to have followed certain of the acute fevers.
The morbid anatomy is interesting. Virchow's view that the delicate
vascular membrane precedes the haemorrhage is undoubtedly correct.
Practically we see one of three conditions in these cases : (a) Subdural
vascular membranes, often of extreme delicacy ; (b) simple subdural ha3m-
orrhage ; (c) combination of the two, vascular membrane and blood-clot.
Certainly the vascular membrane may exist without a trace of haemorrhage
— simply a fibrous sheet of varying thickness, permeated with large vessels,
which may form beautiful arborescent tufts. On the other hand, there
are instances in which the subdural haemorrhage is found alone — in 15 out
of Wigglesworth's 42 cases — but it is possible that in some of these at
least the haemorrhage may have destroyed all trace of the vascular mem-
brane. In some cases a series of laminated clots are found, forming a
layer from 3 to 5 mm. in thickness. Cysts may occur within this mem-
brane. The source of the haemorrhage is probably the dural vessels. Hu-
genin and others hold that the bleeding comes from the vessels of the pia
mater, but certainly in the early stage of the condition there is no evi-
dence of this ; on the other hand, the highly vascular subdural membrane
may be seen covered with the thinnest possible sheeting of clot, which has
evidently come from the dura. The subdural haemorrhage is usually asso-
ciated with atrophy of the convolutions, and it is held that this is one
reason why it is so common in the insane ; but there must be some other
factor than atrophy, or we should meet with it in phthisis and various
cachectic conditions in which the cerebral wasting is as common and almost
as marked as in cases of insanity.
The symptoms are indefinite, and the diagnosis cannot be made with
certainty. Headache has been a prominent symptom in some cases, and
when the condition exists on one side there may be hemiplegia. Exten-
sive bilateral disease may exist without any symptoms whatever.
Diseases of the Pia Mater.
(a) Acute Leptomeningitis. — In this form the exudation is between
the pia and the arachnoid membranes.
Etiology. — Acute inflammation of the pia mater occurs under the
following circumstances : (1) As a result of an eruption of tubercles, most
frequently in the basal meninges, forming the basilar or tuberculous men-
ingitis which has been already considered (see tuberculosis). (2) In the
epidemic cerebro-spinal fever. (3) Secondary to acute general diseases,
8(54: DISEASES OF THE NERVOUS SYSTEM.
more particularly pneumonia, less frequently small-pox, typhoid fever,
rheumatic fever, whooping cough, scarlet fever, and measles. In erysipelas
meningitis may arise either by infection through the blood or by direct
extension. Cases in which the inflammation passes through the bone
are extremely rare ; on the other hand, there are instances of exten-
sive erysipelas of the face in which the disease travels along the nerve-
roots and so reaches the meninges. In this group pneumonia is the only
disease which is frequently followed by meningitis. In one hundred
autopsies at the Montreal General Hospital in pneumonia, meningitis was
found eight times, and I had several opportunities of seeing cases of simi-
lar character in Philadelphia. In septicaemia and pyaemia, including
ulcerative endocarditis in this category, acute meningitis is not very rare.
In ulcerative endocarditis it is common, as may be judged from the statis-
tics which I collected of 209 cases, of which 25 were complicated with
meningitis. No instance has fallen under my observation in connection
with typhoid fever or rheumatic fever.
(4) Injury or disease of the bones of the skull, perforating wounds of the
orbit, or as a sequence of abscess which is the result of injury. Under this
section by far the most frequent cause is necrosis in the petrous portion of
the temporal bone, which may excite either extensive inflammation of the
pia mater or abscess of the brain. (5) In certain constitutional conditions,
such as gout and Bright's disease. This form is usually basilar and comes
on insidiously. Gout is usually mentioned as a cause of meningitis, but it
must be extremely rare. Duckworth does not refer to it in his work, and
the symptoms of the so-called cerebral gout can scarcely be separated from
those of uraemia. On the other hand, in Bright's disease, I have met with
at least three instances of well-marked meningitis, chiefly of the base.
(6) While in a great majority of all cases of basilar meningitis in chil-
dren tubercles may be found, a simple leptomeningitis infantum must also
be recognized. Cases are not very uncommon. Two occurred in debili-
tated children under my care at the Infants' Home in Montreal, and I saw
at least two specimens of the kind at the Philadelphia Hospital. The
condition may be limited to the meninges at the base, particularly at the
posterior part, and to the under surface of the cerebellum. It has also
been termed occlusive meningitis, owing to the fact that involving chiefly
the posterior portion of the meninges about the cerebellum and medulla,
the foramen of Magendie may be closed, with the result of acute, some-
times purulent hydrocephalus, as described by Gee and Barlow. * (7) i
Other causes mentioned are sun-stroke and excessive study, which are
probably doubtful. Syphilis, which is a common cause of chronic menin-
gitis, rarely induces the acute form.
Morbid Anatomy. — The basal or cortical meninges may be involved.
In the form associated with pneumonia and ulcerative endocarditis the
* On the Cervical Opisthotonos of Infants, St. Bartholomew's Hospital Reports, 1878.
AFFECTIONS OF TOE MENINGES. 805
disease is bilateral and usually limited to the cortex. In extension from
disease of the ear it is usually unilateral and may be accompanied with
abscess or with thrombosis of the sinuses. In the non-tuberculous form
in children, in the meningitis of chronic Bright's disease, and in cachectic
conditions the base is usually involved. The vessels are injected, the
subarachnoid fluid is increased and becomes opaque. The arachnoid is
also turbid, and there may be a yellowish- white, creamy exudate, or a gray-
ish-green purulent matter beneath the arachnoid. The interpeduncular
space may be completely filled with the exudate, which extends upon the
under surface of the cerebellum. In the cases secondary to pneumonia
the effusion beneath the arachnoid may be very thick and purulent, com-
pletely hiding the convolutions. The ventricles also may be involved,
though in these simple forms they rarely present the distention and soft-
ening which is so frequent in the tuberculous meningitis.
The leptome?iingitis infantum may present a picture very similar to
the tuberculous disease. There is exudation about the optic chiasma and
in the Sylvian fissures and toward the cerebellum. In some instances we
can say definitely that the condition is not tuberculous only after the most
careful search in the meninges and central arteries, and when no tubercles
are found in the lungs and bronchial glands. In other instances the men-
ingitis may be limited to the posterior part of the base, about the pons,
cerebellum, and fourth ventricle, and the lateral ventricles may present a
most remarkable ependymitis. In a specimen recently shown to me by
W. T. Howard, Jr., from a child aged three months (which had had an
operation performed for imperforate anus), there was posterior basilar
meningitis, the fourth ventricle was filled wdth pus, the walls thickened,
rough, and infiltrated with pus; the lateral ventricles were enormously
distended with pus, and the ependyma, which was from two to three milli-
metres in diameter, was softened and in a condition of purulent infiltra-
tion. A coccus and the bacterium coll commune were found in the pus.
In a somewhat similar case at the Philadelphia Hospital the ependymitis
was limited to the posterior and descending cornua, which were greatly
distended and contained pus. The anterior cornua were little, if at all,
affected, owing doubtless to the influence of gravity. This condition of
intense purulent ependymitis is rare in the adult, but I remember to have
seen an instance of it in a patient of Pepper's at the University Hospital,
Philadelphia.
Symptoms. — I have already spoken at length of the clinical features
of tuberculous meningitis, which is by far the most common and impor-
tant form. 1'he other varieties have a general resemblance to it, particu-
larly those in which the base is affected. I have already, on sevend occa-
sions, called attention to the fact that cortical meningitis is not to be
recognized by any symptoms or set of symptoms from a condition which
may be [» rod need by the poison of many of the specific fevers. In the
cases of so-called cerebral pneumonia, unless the base is involved and the
366 DISEASES OF THE NERVOUS SYSTEM.
nerves affected, the disease is unrecognizable, since identical symptoms
may be produced by intense engorgement of the meninges. In typhoid
fever, in which meningitis is very rare, the twitchings, spasms, and re-
tractions of the neck are almost invariably associated with cerebro-spinal
congestion, not with meningitis.
A knowledge of the etiology gives a very important clew. Thus, in
middle-ear disease the development of high fever, delirium, vomiting,
convulsions, and retraction of the head and neck would be extremely sug-
gestive of meningitis or abscess. Headache, which may be severe and con-
tinuous, is the most common symptom. In the fevers, particularly in
pneumonia, there may be no complaint of headache. Delirium is fre-
quently early, and is most marked when the fever is high. Convulsions
are less common in simple than in tuberculous meningitis. They were
not present in a single instance in the cases which I have seen in pneu-
monia, ulcerative endocarditis, or septicaemia. In the simple meningitis
of children they may occur. Eigidity and spasm or twitchings of the
muscles are more common. Stiffness and retraction of the muscles of
the neck are important symptoms ; but they are by no means constant,
and are most frequent when the inflammation extends to the meninges
of the cervical cord. Vomiting is a common sym.ptom in the early stages,
particularly in basilar meningitis. Constipation is usually present. Optic
neuritis is rare in the meningitis of the cortex, but is not uncommon when
the base is involved.
Important symptoms are due to lesions of the nerves at the base.
Strabismus or ptosis may occur. The facial nerve may be involved, pro-
ducing slight paralysis, or there may be damage to the fifth nerve, pro-
ducing anaesthesia and, if the Gasserian ganglion is affected, trophic changes
in the cornea. The pupils are at first contracted, subsequently dilated,
and perhaps unequal.
Fever is present, moderate in grade, rarely rising above 103°. In the
non-tuberculous leptomeningitis of debilitated children and in Bright's
disease there may be little or no fever. The pulse may be increased in
frequency at first and subsequently is slow and irregular.
Treatment. — There are no remedies which in any way control the
course of acute meningitis. An ice-bag should be applied to the head
and, if the subject is young and full-blooded, general or local depletion
may be practised. Absolute rest and quiet should be enjoined. When
disease of the ear is present, a surgeon should be early called in con-
sultation, and if there are symptoms of meningo-encephalitis which can
in any way be localized trephining should be practised. An occasion-
al saline purge will do more to relieve the congestion than blisters and
local depletion. I have no belief whatever in the efficacy of counter-
irritation to the back of the neck, and to a})ply a blister to a patient
suffering with agonizing headache in meningitis is needlessly to add to
the suffering. If counter-irritation is deemed essential, the thermo-cau-
AFFECTIONS OF THE BLOOD-VESSELS. 867
tery, liglitly applied, is more satisfactory, because the pain inflicted is
transient.
The gastro-intestinal symptoms should receive appropriate treatment.
Gowers states that in two instances of septic meningitis which recovered
the good effects seemed to be due to large doses of the perchloride of
iron. Iodide of potassium and mercury are recommended by some
authors.
The application of an ice-cap, attention to the bowels and stomach,
and keeping the fever at a moderate height by sponging, are the necessary
measures in a disease recognized as almost invariably fatal, and in which
the cases of recovery are extremely doubtful.
(b) Chronic Leptomeningitis. — This is rarely seen apart from syphilis
or tuberculosis, in which the meningitis is associated with the growth of
the granulomata in the meninges and about the vessels. The symptoms
in such cases are extremely variable, depending entirely upon the situa-
tion of the grow^th. They may closely resemble those of tumor and be
associated wdth localized convulsions. The leptomeningitis infantum may
be chronic. In the cases reported by Gee and Barlow the duration in
some instances extended even to a year and a half. The involvement of
the posterior part of the meninges and of the ventricles may lead to dilata-
tion and hydrocephalus. The symptoms upon which these authors lay
stress are convulsions, and retraction of the head, ^vhich is particularly
marked when the child is made to sit up. There may be rigidity of the
limbs and epileptiform convulsions.
II, AFFECTIONS OF THE BLOOD-VESSELS.
Hyperemia.
Congestion of the brain has played an important part in cerebral
pathology. Undoubtedly there are great variations in the amount of
blood in the cerebral vessels ; this is universally conceded, but how far
these changes are associated with a definite group of symptoms is not
quite so* clear. The hypersemia may be either active or passive.
Active hypercemia is associated with febrile conditions, with increased
action of the heart, chilling of the surface, contraction of the superficial
vessels, and with the suppression of certain customary discharges. Among
other recognized causes are plethora, functional irritation, such as is asso-
ciated with excessive brain work, and the action of certain substances, such
as alcohol and nitrite of amyl.
Passive hypercnmia results from obstruction in the cerebral sinuses
and veins, engorgement in the lesser circulation, as in mitral stenosis,
emphysema, from pressure on the superior cava by aneurisms and tumors,
and in the venous engorgement which takes place in prolonged straining
66
g08 DISEASES OF THE NERVOUS SYSTEM.
efforts. In its most intense form it is seen in the compression of the
superior cava by tumors and in death from strangulation.
The anatomical changes in congestion of the brain are by no means
striking. Active hyperaemia is never visible post mortem. The veins of
the cortex are distended, the gray matter has a deeper color, and its
vessels are full. The arteries at the base and in the Sylvian fissures con-
tain blood. Nothing, however, can be more uncertain or indefinite than
the post-mortem appearances of hyperaemia of the brain. The most intense
distention of the vessels is seen in early death during the specific fevers,
or in the secondary passive congestion due to obstruction in the superior
cava or in the lesser circulation.
SymptoniS. — There are no characteristic or constant features of
cerebral hyperaemia. It may exist in the most extreme grade without the
slightest disturbance of the cerebral functions, as is witnessed frequently
in the pressure of tumors on the superior vena cava. How far the head-
ache and delirium of the early stage of the infectious fevers is to be
assigned to hyperaemia of the blood-vessels of the brain it is not easy to
determine. The headache, dizziness, and unpleasant sensations in aortic
insufficiency and in some instances of hypertrophy of the heart may be
due to the cerebral congestion.
As a separate clinical entity, congestion of the brain rarely comes
under observation. I have no knowledge of instances associated with
delirium, fever, insomnia, and convulsions, or of the so-called apoplectiform
variety described by some writers. Very plethoric persons are subject to
attacks of headache with flushing of the face and irritability of temper,
attacks which may recur frequently and are sometimes relieved by bleed-
ing at the nose. These are usually attributed to congestion of the brain.
When passive hyperaemia reaches a high grade, there may be torpor, dul-
ness of the intellect, and ultimately deep coma.
AlS'^MIA.
This may be induced by loss of blood, either quickly, as in haemor-
rhage, or gradually, as in the severe primary and secondary anaemias.
The anaemia may be local and due to causes which interfere with the blood
supply to the brain, as narrowing of the vessels by endarteritis, pressure,
narrowing of the aortic orifice, or it may follow an unequal distribution
of the blood in consequence of dilatation of certain vascular territories.
Thus, rapid distention of the intestinal vessels, such as occurs after the
removal of ascitic fluid, may cause sudden death from cerebral anaemia.
The commonest illustration of this is the fainting fit from emotion, in
which the blood supply to the brain is insufficient on account of the
diminished arterial pressure. Anaemia of the cerebral vessels may be
caused by pressure of fluid in the ventricles. The partial anaemia results
from obliteration of branches of the circle of Willis by embolism or throm-
AFFECTIONS OF THE BLOOD-VESSELS. 869
bosis. Ligature of one carotid sometimes causes a transient marJied anae-
mia and disturbance of function on one side of the brain.
The anatomical condition of the brain in anajmia is very striking.
The membranes are pale, only the large veins are full, the small vessels
over the gyri are empty, and an unusual amount of cerebro-spinal fluid is
present. On section both the gray and white matter look extremely pale
and the cut surface is moist. Very Iqw pu7icta vasculosa are seen.
Symptoms. — The effects of anaemia of the brain are well illustrated
by a fainting fit in which loss of consciousness follows the heart weakness.
When the result of haemorrhage, there are drowsiness, giddiness, inability
to stand, flashes of light, and noises in the ear ; the respiration becomes hur-
ried ; the skin is cool sind covered with sweat ; and gradually, if the bleed-
ing continues, consciousness is lost and death may occur with convulsions.
In ordinary syncope the loss of consciousness is usually transient and
the- recumbent posture alone may suffice to restore the patient to con-
sciousness. In the more chronic forms of brain anaemia, such as result
from the gradual impoverishment of the blood, as in protracted illness or
in starvation, the condition known as irritable weakness results. Mental
eifort is difficult, the slightest irritation is followed by undue excitement,
the patient complains of giddiness and noises in the ears, or there may be
hallucinations or delirium. These symptoms are met with in an extreme
grade as a result of prolonged starvation.
An interesting set of symptoms, to which the term liydroceplialoid was
applied by Marshall Hall, occurs in the debility produced by prolonged
diarrhoea in children. The child is in a semi-comatose condition with the
eyes open, the pupils contracted, and the fontanelle depressed. In the
earlier period there may be convulsions. The coma may gradually deepen,
the pupils become dilated, and there may be strabismus and even retrac-
tion of the head, symptoms which closely simulate basilar meningitis.
(Edema of the Brain.
In the pathology of brain lesions oedema formerly played a role almost
equal in importance to congestion. It occurs under the following condi-
tions : In general atrophy of the convolutions, in which case the oedema
is represented by an increase in the cerebro-spinal fluid and in that of the
meshes of the pia. In extreme hyperaemia from obstruction, as in mitral
stenosis or in tumors, there may be a condition of congestive oedema, in
which, in addition to great filling of the blood-vessels, the substance of
the brain itself is unusually moist. The most acute oedema is a local pro-
cess found around tumors and abscesses. An intense infiltration, local or
general, may occur in I5right's disease, and to it, as Traube suggested, cer-
tain of the uraemic symptoms may be due.
The anatomical changes are not unlike those of anaemia. When a
sequence of progressive atrophy, the fluid is chiefly within and beneath
870 DISEASES OF THE NERVOUS SYSTEM.
the membranes. The brain substance is ana3mic and moist, and has a
wet, glistening appearance, which is very characteristic. In some in-
stances the oedema is more intense and local and the brain substance may
look infiltrated with fluid. The amount of fluid in the ventricles is usu-
ally increased.
The symptoms are in great part those of anaemia, and are not well
defined. As just stated, some of the cerebral features of uraemia may
depend upon it. Of late years cases have been reported by Raymond,
Tenneson, and Dercum, in which unilateral convulsions or paralysis have
occurred in connection with chronic Bright's disease, and in which the
condition appeared to be associated with oedema of the brain. The older
writers laid great stress upon an apoplexia serosa, ^which may really have
been a general oedema of the brain.
Cerebral Hjsmorrhage.
The bleeding may come from branches of either of the two great
groups of cerebral vessels — the basal, comprising the circle of Willis and
the central arteries passing from it, or the cortical group, the anterior,
middle, and the posterior cerebral vessels. In a majority of the cases the
haemorrhage is from the central branches, more particularly from those
given off by the middle cerebral arteries in the anterior perforated spaces,
and which supply the corpora striata and internal capsules. One of the
largest of these branches which passes to the third division of the lenticular
nucleus and to the hinder part of the internal capsule is so frequently in-
volved in haemorrhage that it has been called by Charcot the artery of
cerebral licemorrliage. The bleeding may be into the substance of the
brain, to which alone the term cerebral apoplexy is applied, or into the
membranes, in which case it is termed meningeal haemorrhage ; both,
however, are usually included under the terms intracranial or cerebral
haemorrhage.
Etiology. — The conditions which produce lesions of the blood-ves-
sels play a very important part ; thus the natural tendency to degeneration
of the vessels in advanced life makes apoplexy much more common after
the fiftieth year. It may, however, occur in children under ten. On
account of the greater liability to arterial disease (associated probably
with muscular exertion and the abuse of alcohol), men are more subject
to cerebral haemorrhage than women. Heredity was formerly thought
to be an important factor in this affection, and the apoplectic habitus or
build is still referred to. By this is meant a stout, plethoric body of me-
dium size, witli a short neck. Heredity influences cerebral haemorrhage
entirely through the arteries, and there are families in which they degener-
ate early, usually in association with renal changes. The secondary hyper-
trophy of the heart brings with it serious dangers, which have already
been discussed in the section upon arteries. The three special factors in
AFFECTIONS OF THE BLOOD-VESSELS. 871
inducing artcrio-sclerosis — the abuse of alcohol, syphilis, and prolonged
muscular exertion — are found to be important antecedents in a large num-
ber of cases of cerebral haemorrhage.
The endocarditis of rheumatism and other fevers may indirectly lead
to apoplexy by causing embolism and aneurism of the vessels of the
brain. Cerebral haemorrhage occurs occasionally in the specific fevers
and in profound alterations of the blood, as in leukemia and pernicious
anaemia. The actual exciting cause of the haemorrhage is not evident in
the majority of cases. The attack may be sudden and without any pre-
liminary symptoms. In other instances violent exertion, particularly
straining efforts or, the excited action of the heart in emotion may cause
a rupture.
Morbid Anatomy. — The lesions causing apoplexy are almost in-
variably in the cerebral arteries, in which the following changes may lead
directly to it :
(a) Periarteritis with the production of miliary aneurisms, rupture of
which is the most common cause of cerebral haemorrhage. They occur most
frequently on the central arteries, but also on the smaller branches of the
cortical vessels. On section of the brain substance they may be seen as
localized, small dark bodies about the size of a pin's head. Sometimes
they are seen in numbers upon the arteries carefully withdrawn from the
anterior perforated spaces. According to Charcot and Bouchard, who have
described them, they are most frequent in the central ganglia. In apo-
plexy after the fortieth year if sought for they are rarely missed.
(b) Aneurism of the branches of the circle of Willis. These are by
no means uncommon, and will be considered subsequently.
(c) Endarteritis and periarteritis in the cerebral vessels most commonly
lead to apoplexy by the production of aneurisms^ either miliary or coarse.
There are instances in which the most careful search fails to reveal any-
thing but diffuse degeneration of the cerebral vessels, particularly of the
smaller branches; so that we must conclude that spontaneous rupture
may occur without the previous formation of aneurism.
The haemorrhage may be meningeal, cerebral, or intraventricular.
Meningeal HcBmorrhage may be outside the dura, between this mem-
brane and the bone, or between the dura and arachnoid, or between the
arachnoid and the pia mater. The following are the chief causes of this
form of haemorrhage : Fracture of the skull, in which case the blood usu-
ally comes from the lacerated meningeal vessels, sometimes from the torn
sinuses. In these cases the blood is usually outside the dura or between it
and the arachnoid. The next most frequent cause is rupture of aneurisms
on the larger cerebral vessels. The blood is usually subarachnoid. An
intracerebral haemorrhage may burst into the meninges. A special form
of meningeal haemorrhage is found in the new-born, associated with injury
during birth. And lastly, meningeal haemorrhage may occur in the con-
Btitutional diseases and fevers. The blood may be in a large quantity at
872 DISEASES OP THE NERVOUS SYSTEM.
tliG base ; in cases of ruptured aneurism, particularly, it may extend into
the cord or upon the cortex. Owing to the greater frequency of the aneu-
risms in the middle cerebral vessels, the Sylvian fissures are often dis-
tended with blood.
Intracerebral licemorrhage is most frequent in the neighborhood of the
corpus striatum, particularly toward the outer section of the lenticular
nucleus. The haemorrhage may be small and limited to the lenticular
body and the internal capsule, or it may break the centrum ovale, or burst
into the lateral ventricle, or extend to the insula. Haemorrhages con-
fined to the white matter — the centrum ovale — are rare. Localized bleed-
ing may occur in the crura or in the pons. Haemorrhage into the cere-
bellum is not uncommon, and usually comes from the superior cerebellar
artery. The extravasation may be limited to the substance or rupture
into the fourth ventricle. Twice I have known sudden death in girls
under twenty-five to be due to cerebellar haemorrhage.
Ventricular Hcemorrhage. — This rarely comes from the vessels of the
plexuses or of the walls. It is not infrequent in early life and may occur
during birth. Of 94 cases collected by Edward Sanders, 7 occurred during
the first year, and 14 under the twentieth year. In the cases which I have
seen in adults it has almost always been caused by rupture of a haemor-
rhage in the neighborhood of the caudate nucleus. The blood may be
found in one ventricle only, but more commonly it is in both lateral ven-
tricles, and may pass into the tliird ventricle and through the aqueduct
of Sylvius into the fourth ventricle, forming a complete mould in blood
of the ventricular system.
Subsequent Changes. — The blood gradually changes in color, and ulti-
mately the haemoglobin is converted into the reddish-brown ha3matoidin.
Inflammation occurs about the apoplectic area, limiting and confining it,
and ultimately a definite wall may be produced, inclosing a cyst with fluid
contents. In other instances a cyst is not formed, but the connective-tissue
proliferates and leaves a pigmented scar. In meningeal haemorrhage the
effused blood may be gradually absorbed and leave only a staining of the
membranes. In other cases, particularly in infants, when the effusion is
cortical and abundant, there may be localized wasting of the convolutions
and the production of a cyst in the meninges. Possibly certain of the
cases of porencephaly are caused in this way.
Secondary degeneration follows when the motor cortex or motor path
is involved. Thus, in persons dying some years after a cerebral apoplexy
which has produced hemiplegia, the degeneration may be traced in the
cms, in the anterior part of the pons, in the pyramidal fibres of the me-
dulla, in the direct fibres of the cord of the same side, and in the crossed
pyramidal fibres of the opposite side (Fig. 3).
Symptoms.- — These may be divided into primary, or those connected
with the onset, and secondary, or those which develop later after the early
manifestations have passed away.
AFFECTIONS OF THE BLOOD-VESSELS. 873
Primary Sy7nptoms. — Premonitory indications are rare. As a rule,
the patient is seized while in full health or about the performance of some
every-day action, occasionally an action requiring strain or extra exer-
tion. Now and then instances are found in which there are sensations of
numbness or tingling or pains in the limbs, or even choreiform movements
in the muscles of the opposite side, the so-called prehemiplegic chorea.
The onset of the apoplexy, as cerebral haemorrhage is usually called, varies
greatly. There may be sudden loss of consciousness and complete relaxa-
tion of the extremities. In such instances the name apoplectic stroke is
particularly appropriate. In other cases the onset is more gradual and
the loss of consciousness may not occur for a few minutes after the patient
has fallen, or after the paralysis of the limbs is manifest. In the apoplec-
tic attack the condition is as follows : There is deep unconsciousness ; the
patient cannot be roused. The face is injected, sometimes cyanotic, or
of an ashen-gray hue. The pupils vary ; usually they are dilated and in-
active. The respirations are slow, noisy, and accompanied with stertor.
Sometimes the Cheyne-Stokes rhythm may be present. The pulse is usu-
ally full, slow, and of increased tension. The temperature may be normal,
but is often found subnormal, and, as in a case reported by Bastian, may
sink below 95°. In cases of basal haemorrhage the temperature, on the
other hand, may be high. The urine and faeces are usually passed invol-
untarily. Convulsions are not common. It may be difficult to decide
whether the condition is apoplexy associated with hemiplegia or sudden
coma from other causes. An indication of hemiplegia may be discovered
in the difference in the tonus of the muscles on the two sides. If the arm
or the leg is lifted, it drops " dead " on the affected side, while on the
other it falls more slowly. Eigidity also may be present. In watching
the movements of the facial muscles in the stertorous respiration it will
be seen that on the paralyzed side the relaxation permits the cheek to be
blown out in a more marked manner. The head and eye may be turned
strongly to one side — conjugate deviation.
In other cases, in which the onset is not so abrupt, the patient may
not lose consciousness, but in the course of a few hours there is loss of
power, unconsciousness gradually develops, and deepens into profound
coma. This is sometimes termed ingravescent apo2:)Iexy. The attack may
occur during sleep. The patient may be found unconscious, or wakes to
find that the power is lost on one side. Small haemorrhages may cause
hemiplegia without loss of consciousness, more particularly when they are
in the territory of the central arteries.
Usually within forty-eight hours after the onset of an attack there is
febrile reaction, and more or less constitutional disturbance associated
with inflammatory changes about the haemorrhage. The patient may
die in this reaction, or, if consciousness has been regained, there may be
delirium or recurrence of the coma. At this period the so-called early
rigidity may develop in the paralyzed limbs. Trophic changes may occur,
874 DISEASES OF THE NERVOUS SYSTEM.
such as sloughing or the formation of vesicles. The most serious of these
is the sloughing eschar of the lower part of the back, or on the paralyzed
side, which may appear within forty-eight hours of the onset and is usually
of grave significance. The congestion at the bases of the lungs so com-
mon in apoplexy is regarded by some as a trophic change.
Conjugate Deviation. — In a right hemiplegia the eyes and head may
be turned to the left side ; that is to say, the eyes look toward the cere-
bral lesion. This is almost the rule in conjugate deviation of the head
and eyes which occurs early in hemiplegia. When, however, convulsions
or spasm develop or the state of so-called early rigidity in hemiplegia, the
conjugate deviation of the head and eyes may be in the opposite direction ;
that is to say, the eyes look away from the lesion and the head is rotated
toward the convulsed side. This symptom may be associated with cortical
lesions, particularly, according to some authors, when in the neighbor-
hood of the supramarginal and angular gyri. It may also occur in a
lesion of the internal capsule or in the pons, but in the latter situation
the conjugate deviation is the reverse of that which occurs in other
cases, as the patient looks away from the lesion, and in spasm or con-
vulsion looks toward the lesion. In cases in which consciousness is re-
stored and the patient improves, the unilateral paralysis which persists is
known as
Hemiplegia. — Hemiplegia is complete when it involves face, arm, and
leg, or partial when it involves only one or other of these parts. This
may be the result of a lesion [a) of the motor cortex ; (^) of the pyramidal
fibres in corona radiata and in the internal capsule ; (^) of a lesion in the
crus cerebri ; or [d) in the pons Varolii (see Fig. 3, x^ y, z). Haemorrhage
is perhaps the most common cause, but tumors and spots of softening may
also induce it. The special details of the hemiplegia may here be consid-
ered. The face is involved on the same side as the arm and leg. This
results from the fact that the facial muscles stand in precisely the same re-
lation to the cortical centres as those of the arm and leg, the fibres of the
upper motor segment of the facial nerve from the cortex decussating just
as do those of the nerves of the limbs. The facial paralysis is partial, in-
volving only the lower portion of the nerve, so that the orbicularis oculi
and the frontalis muscles are uninvolved. The signs of the facial paralysis
are usually well marked. There may be a slight difficulty in elevating the
eyebrows or in closing the eye on the paralyzed side. The hypoglossal
nerve also is involved. In consquence, the patient cannot put out the
tongue straight, but it deviates toward the paralyzed side, inasmuch as
the genio-hyo-glossus of the sound side is unopposed. When the hemi-
plegia is on the right side there may be aphasia.
The arm is, as a rule, more completely paralyzed than the leg. The
loss of power may be absolute or partial. In severe cases it is at first
complete. In others, when the paralysis in the face and arm is com-
plete that of the leg is only partial. The face and arm may alone be par-
AFFECTIONS OF THE BLOOD-VESSELS. 875
alyzed, while the leg escapes. Less commonly the leg is more affected
than the arm, and the face may be only slightly involved.
Certain muscles escape in hemiplegia, particularly those associated in
symmetrical movements, as the thoracic and abdominal muscles, a fact
which Broadbent explains by supposing that as the spinal nuclei control-
ling these movements on both sides constantly act together, they may, by
means of this intimate connection, be stimulated by impulses coming from
only one side of the brain.
Crossed liemiplegia occurs when a lesion is in the lower section of the
pons Varolii (Fig. 3, z)^ in which the facial nerve is involved as it passes
through the pons after it has left its nucleus ; Avhereas, the motor fibres
involved in the lesion are above the point of their decussation, so that
facial paralysis occurs on the same side as the lesion, and paralysis of the
arm and leg on the opposite side.
The sensory disturbances are variable. Hemiansesthesia may coexist
with hemiplegia, but in many instances there is only slight numbness of
sensation. When the hemianaesthesia is marked, it is usually the result
of a lesion in the internal capsule. In C. L. Dana's study of sensory
localization he found that anaesthesia of organic cortical origin was always
limited or more pronounced in certain parts, as the face, arm, or leg, and
was generally incomplete. Total anaesthesia was either of functional or
subcortical origin. Marked anaesthesia was much more common in soft-
ening than in haemorrhage. Complete hemianesthesia is certainly rare
in haemorrhage.
Disturbance of the special senses is not common. Hemianopia may
exist .on the same side as the lesion, and there may be diminution in the
acuteness of the senses of hearing, taste, and smell.
As a rule, there is no wasting of the paralyzed limbs. The deep
reflexes are increased on the paralyzed side, and ankle clonus may be
present. The plantar and other superficial refiexes are usually dimin-
ished. The sphincters are not affected.
The course of tlie disease depends upon the situation and extent of
the lesion. If slight, the hemiplegia may disappear completely within a
few days or a few weeks. In severe cases the rule is that the leg gradually
recovers before the arm, and the muscles of the shoulder girdle and upper
arm before those of the forearm and hand. The face may recover quickly.
Except in the very slight lesions, in which the hemiplegia is transient,
changes take place which may be grouped as
Secondary Symptoms. — These correspond to the chronic stage. In a
case in which little or no improvement takes place within eight or ten
weeks, it will be found that the paralyzed limbs undergo certain changes.
The leg, as a rule, recovers enough power to enable the patient to get
about, although the foot is dragged. In both arm and leg the condition
of secondary contraction or late rigidity comes on and is always most
marked in tlie uj)pcr extremity. The arm becomes permanently flexed at
S76 DISEASES OF THE NERVOUS SYSTEM.
the elbow and resists all attempts at extension. The wrist is flexed
upon the forearm and the fingers upon the hand. The position of the
arm and hand is very characteristic. There is frequently, as the con-
tractures develop, a great deal of pain. In the leg the contracture is
rarely so extreme. The loss of power is most marked in the muscles of
the foot, and to prevent the toes from dragging the knee in walking is
much flexed, or more commonly the foot is swung round in a half-
circle.
The reflexes are at this stage greatly increased. These contractures
are permanent and incurable, and are associated with a secondary descend-
ing sclerosis of the motor path. There are instances, however, in which
rigidity and contracture do not occur, but the arm remains flaccid, the
leg having regained its power. This hemipUgie flasque of Bouchard is
found most commonly in children. Among other secondary changes in
late hemiplegia may be mentioned the following : Tremor of the affected
limbs, post-paralytic chorea, the mobile spasm known as athetosis, arthropa-
thies in the Joints of the affected side, and muscular atrophy. Athetosis
and post-hemiplegic chorea will be considered in the hemiplegia of chil-
dren. A word may here be said upon the subject of muscular atrophy of
cerebral origin.
As a rule, atrophy is not a marked feature in hemiplegia, but in some
instances it does develop. It has been shown to be due in some cases to
secondary alterations in the gray matter of the anterior horns, as in a case
reported by Charcot. Recently, however, attention has been called by
Quincke to the fact that atrophy may follow as a direct result of the cere-
bral lesion. In his case, atrophy of the arm followed the development of
a glioma in the anterior central convolutions. The gray matter of the
anterior horns was normal. This wasting of cerebral origin occurs most
frequently in children.
Diagnosis. — There are three groups of cases which offer increasing
difficulty in recognition.
(1) Cases in which the onset is gradual, a day or two elapsing before
the* paralysis is fully developed and consciousness completely lost, are
readily recognized, though it may be difficult to determine whether the
lesion is due to thrombosis or to haemorrhage.
(2) In the sudden apoplectic stroke in which the patient rapidly loses
consciousness, the difficulty in diagnosis may be still greater, particularly
if the patient is in deep coma when first seen.
The first point to be decided is the existence of hemiplegia. This may
be difficult, although, as a rule, even in deep coma the limbs on the para-
lyzed side are more flaccid and drop instantly when lifted ; whereas, on
tlie non-paralyzed side the muscles retain some degree of tonus. The
reflexes may be increased on the affected side and there may be conjugate
deviation of the head and eyes. Rigidity in the limbs of one side is in
favor of a hemiplcgic lesion. It is practically impossible in a majority of
AFFECTIONS OF THE BLOOD-VESSELS. 877
these cases to say whether the lesion is due to hasmorrhage, embolism, or
thrombosis.
(3) Large haemorrhage into the ventricles or into the pons may pro-
duce sudden loss of consciousness with complete relaxation, so that the
condition may simulate coma from uraemia, alcoholism, opium poisoning,
or epilepsy. The previous history and the mode of onset may give valua-
ble information. In epilepsy convulsions have preceded the coma; in
alcoholism there is a history of constant drinking, while in oi)ium poison-
ing the coma develops more gradually ; but in many instances the diffi-
culty is practically very great, and on more than one occasion I have seen
mortifying post-mortem disclosures under these circumstances. In ven-
tricular hgemorrhage the coma is sudden and develops rapidly. The
hemiplegic symptoms may be transient, quickly giving place to complete
relaxation. Convulsions occur in many cases, and may be the very symp-
tom to lead astray — as in a case of ventricular hasmorrhage which occurred
in a puer^^eral patient, in whom, naturally enough, the condition was
thought to be uraemic. Eigidity is often present. In haemorrhage into
the pons convulsions are frequent. The pupils may be strongly con-
tracted, conjugate deviation may occur, and the temperature is apt to rise
rapidly. The contraction of the pupils in pontine haemorrhage naturally
suggests opium poisoning. The difference in temperature in the two con-
ditions is a valuable diagnostic point.
It may be impossible at first to give a definite diagnosis. In admissions
to hospitals or in emergency cases the ph3^sician should be particularly
careful about the following points : The examination of the head for in-
jury or fracture ; the urine should be tested for albumen and examined
for sugar ; a careful examination should be made of the limbs with refer-
ence to their degree of relaxation or the presence of rigidity, and the con-
dition of the reflexes ; the state of the pupils should be noted and the
temperature taken. The most serious mistakes are made in the case of
patients who are drunk at the time of the attack, a combination by no
means uncommon in the class of patients admitted to hospital. Under
these circumstances the case may be looked upon as one of alcoholic coma.
It is best to regard each case as serious and to bear in mind that this is a
condition in which, above all others, mistakes are common.
Prognosis. — From cortical haemorrhage, unless very extensive, the
recovery may be complete without a trace of contracture. This is more
common when the haemorrhage follows injury than when it results from
disease of the arteries. Infantile meningeal haemorrhage, on the other
hand, is a condition which may produce idiocy or spastic diplegia.
Large haemorrhages into the corona radiata and those which rupture
into the ventricles rapidly prove fatal.
The hemiplegia which follows lesions of the internal capsule, the re-
sult of rupture of the artery of the corpus striatum, is usually persistent
and followed by contracture. When the posterior fibres are involved
878 DISEASES OF THE NERVOUS SYSTEM.
there may be liemiangesthesia, and later hemichorea or athetosis. In any
case of cerebral apoplexy the following symptoms are of grave omen : per-
sistence or deepening of the coma during the second and third day ; rapid
rise in temperature within the first forty-eight hours after the initial fall.
In the reaction which takes place on the second or third day, the tem-
perature usually rises, and its gradual fall on the third or fourth day with
return of consciousness is a favorable indication. The rapid formation of
bed-sores, particularly the malignant decubitus of Charcot, is a fatal indi-
cation. The occurrence of albumen and sugar, if abundant, in the urine
is an unfavorable symptom.
When consciousness returns and the patient is improving, the ques-
tion is anxiously asked as to the paralysis. The extent of this cannot be
determined for some weeks. With slight lesions it may pass off entirely.
If persistent at the end of a month some grade of permanent palsy is cer-
tain to remain, and gradually the late rigidity supervenes.
Embolism akd Thrombosis (Cerebral Softening),
(a) Embolism. — The embolus usually enters the carotid, rarely the
vertebral artery. In the great majority of cases it comes from the left
heart and is either a vegetation of a fresh endocarditis or, more com-
monly, of a recurring endocarditis, or from the segments involved in
an ulcerative process. Less often the embolus is a portion of a clot
Avhich has formed in the auricular appendix. Portions of clot from an
aneurism, thrombi from atheroma of the aorta, or from the territory
of the pulmonary veins, may also cause blocking of the branches of the
circle of Willis. In the puerperal condition cerebral embolism is not in-
frequent. It may occur in women with heart-disease, but in other in-
stances the heart is uninvolved, and the condition has been thought to be
associated with the development of heart-clots, owdng to increased coagu-
lability of the blood. A majority of cases of embolism occur in chronic
heart-disease. Cases are rare in the acute endocarditis of rheumatism,
chorea, and febrile conditions. It is much more common in the secondary
recurring endocarditis which attacks old sclerotic valves. The embolus
most frequently passes to the left middle cerebral artery, as it enters the
left carotid of tener than the right because of the more direct course of the
blood in the former. The posterior cerebral and the vertebral are less
often affected. A large plug may lodge at the bifurcation of the basilar.
Embolism of the cerebellar vessels is rare.
Embolism occurs more frequently in women, owing, no doubt, to the
greater frequency of mitral stenosis. Contrary to this general statement,
Newton Pitt's statistics of 79 cases at Guy's Hospital indicate, however,
that males are more frequently affected ; for in this series there were 44
males and 35 females.
(b) Thrombosis. — Clotting of blood in the cerebral vessels occurs about
AFFECTIONS OF THE BLOOD-VESSELS. 879
an embolus, as the result of a lesion of the arterial wall (either endarteritis
with or without atheroma or, particularly, the syphilitic arteritis), in aneu-
risms both coarse and miliary, and very rarely as a result of abnormal con-
ditions of the blood. Thrombosis of the cerebral vessels occasionally fol-
lows ligation of the carotid artery. The thrombosis is most common in the
middle cerebral and in the basilar arteries.
Anatomical Changes folloiving Thrombosis and Embolism. — Degenera-
tion and softening of the territory supplied by the vessels is the ultimate
result of the arterial obstruction. Blocking in a terminal artery may be
followed by a condition resembling infarct, in which the territory is deep-
ly infiltrated with blood. More commonly the change is much less strik-
ing, and the affected region may look only a little paler than normal or
slightly softer. Gradually the process of softening proceeds, the tissue
is infiltrated with serum and is moist, the nerve-fibres degenerate and
become fatty. The neuroglia is swollen and oedematous. The color of
the softened area depends upon the amount of blood. The haemoglobin
undergoes gradual transformation, and the early red color may give place
to yellow. Formerly much stress was laid upon the difference between
red, yelloiu, and white softening. The red and yellow are seen chiefly
on the cortex. Sometimes the red softening is particularly marked in
cases of embolism and in the neighborhood of tumors. The gray matter
shows many punctiform haemorrhages — capillary aj^oplexy. There is a
variety of yellow softening — the plaques jaunes — common in elderly
persons, which occurs in the gray matter of the convolutions. The spots
are from one to two centimetres in diameter, the edges cleanly cut, and
the softened area is represented by either a turbid, yellow material, or in
some instances there is a space crossed by fine trabeculae, in the meshes of
which there is fluid. They result from fatty degeneration of the periph-
eral cortical arteries ; less often the hyaline change is present. White
softening occurs most frequently in the white matter, and is seen best
about tumors and abscesses. Inflammatory changes are common in and
about the softened areas. When the embolus is derived from an infected
focus, as in ulcerative endocarditis, suppuration may follow. The final
changes vary very much. The degenerated and dead tissue elements are
gradually but slowly removed, and if the region is small may be replaced
by growth of connective tissue and the formation of a scar. In larger
regions the resorption results in the formation of a cyst, which may be
crossed by connective-tissue trabeculae. It is surprising for how long an
area of softening may persist without much change.
The position and extent of the softening depend upon the obstructed
artery. An embolus which blocks the middle cerebral at its origin in-
volves both the arteries in the anterior perforated space and the cortical
branches, and in such a case there is softening in the neighborhood of the
corpus striatum, as well as in part of the region supplied by the corti-
cal vessels. The freedom of anastomosis between these branches varies
880 DISEASES OF THE NERVOUS SYSTEM.
a good deal. Thus, there are instances of embolism of the middle cere-
bral artery in which the softening has only involved the territory of the
central branches, in which case blood has reached the cortex through the
anterior and posterior cerebrals. "When the middle cerebral is blocked (as
is perhaps oftenest the case) beyond the point of origin of the central
arteries, one or other of its branches is usually most involved. The embo-
lus may lodge in the vessel passing to the third frontal convolution, or in
the artery of the ascending frontal or ascending parietal ; or it may lodge
in the branch passing to the supramarginal and angular gyri, or it may
enter the lowest branch which is distributed to the upper convolutions of
the temporo-sphenoidal lobe. These are practically terminal arteries, and
instances frequently occur of softening limited to a part, at any rate, of
the territory supplied by them. Some of the most accurate focalizing
lesions are in this way produced.
Symptoms. — Extensive thrombotic softening may exist without any
symptoms. It is not uncommon in the post-mortem examination of the
bodies of elderly persons to find the plaques jaunes scattered over the
convolutions. So, too, softening may take place in the " silent " regions,
as they are termed, without exciting any symptoms. When the central or
cortical branches of the middle cerebral arteries are involved the symp-
toms are similar to those of haemorrhage. Permanent or transient hemi-
plegia results. When the central arteries are involved the softening in
the internal capsule is commonly followed by permanent hemiplegia.
There are certain peculiarities associated with embolism and with throm-
bosis respectively.
In emholism the patient is usually the subject of heart-trouble, or there
exist some of the conditions already mentioned. The onset is sudden,
without premonitory symptoms. When the embolism blocks the left
middle cerebral artery the hemiplegia is usually associated with aphasia.
In thromhosis, on the other hand, the onset is more gradual ; the patient
has previously complained of headache, vertigo, tingling in the fingers ;
the speech may have been embarrassed for some days ; the patient has
had loss of memory or is incoherent, or paralysis begins at one part, as
the hand, and extends slowly, and the hemiplegia may be incomplete or
variable. Abrupt loss of consciousness is much less common, and when
the lesion is small consciousness is retained. Thus, in thrombosis due to
syphilitic disease, the hemiplegia may come on gradually without the
slightest disturbance of consciousness.
The hemiplegia following thrombosis or embolism has practically the
characteristics, both primary and secondary, described under haemorrhage.
The following may be the effects of blocking the different vessels :
(ff) Vcrtehrah — The left branch is more frequently plugged. The effects
are involvement of the nuclei in the medulla and symptoms of acute
bulbar paralysis. It rarely occurs alone ; more commonly with
{b) Blocking of the basilar artery. When this is entirely occluded,
AFFECTIONS OF THE BLOOD-VESSELS. 881
there may be bilateral paralysis from involvement of both motor paths.
Bulbar symptoms may be present ; rigidity or spasm may occur. The
temperature may rise rapidly. The symptoms, in fact, are those of apo-
plexy of the pons.
(c) The jjosfcrior cerehral supplies the occipital lobe on its inner face
and the greater part of the temporo-sphenoidal lobe. Localized areas of
softening may exist without symptoms. Blocking of the branch passing
to the cuneus may be followed by hemianopia. Hemianaesthesia may re-
sult from involvement of the posterior part of the internal capsule.
(d) Internal Carotid. — The symptoms are variable. As is Avell known,
the vessel is in a majority of cases ligated without risk. In other in-
stances transient hemiplegia follows ; in others again the hemiplegia is per-
manent. These variations depend on the anastomoses in the circle of Wil-
lis. If these are large and free, no paralysis follows, but in cases in which
the posterior communicating and the anterior communicating vessels are
small or absent, the paralysis may persist. In ~^o. 7 of my Elwyn series
of cases of infantile hemiplegia, the woman, aged twenty-four, Avhen six
years old, had the right carotid ligated for abscess following scarlet fever,
with the result of permanent hemiplegia. Blocking of the internal ca-
rotid within the skull by thrombosis or embolism is followed by hemiplegia,
coma, and usually death. The clot is rarely confined to the carotid
itself, but spreads into its branches and may involve the ophthalmic
artery.
(e) Middle Cerehral. — This is the vessel most commonly involved, and,
as already mentioned, if plugged before the central arteries are given off,
permanent hemiplegia usually follows from softening of the internal cap-
sule. Blocking of the branches beyond this point may be followed by
hemiplegia, which is more likely to be transient, involves chiefly the arm
and face, and if on the left side is associated with aphasia. The individual
branches passing to the third frontal, ascending parietal, to the supramar-
ginal and angular gyri, or to the temporal gyri may be plugged.
(/) Anterior Cerebral. — Xo symptoms may folloAv, and even when the
branches which supply the paracental lobule and the top of the ascending
convolutions are plugged the branches from the middle cerebral are usu-
ally able to effect a collateral circulation in these parts. Hebetude and
dulness of intellect may occur with obstruction of the vessel.
There is unquestionably greater freedom of communication in the
cortical branches of the different arteries than is usually admitted, al-
though it is not possible, for example, to inject the posterior cerebral
through the middle cerebral, or the middle cerebral from the anterior ;
but the absence of softening in some instances in which smaller branches
are blocked shows how completely may be the compensation. The dila-
tation of the collateral branches may take place very rapidly ; thus a pa-
tient with chronic nephritis died about twenty-four hours after the hemi-
plegic attack. There were recent vegetations on the mitral and an embolus
882 DISEASES OF THE NERVOUS SYSTEM.
in the right middle cerebral artery just beyond the first two branches
(temporal). The central portion of the hemisphere was swollen and
cedematous. The right anterior cerebral was greatly dilated, and by
measurement its diameter was found to be nearly three times that of the
left.
Treatment of Cerebral Haemorrhage. — The patient should be
placed with the head high, and measures immediately taken to reduce the
arterial pressure. Of these the most rapid and satisfactory is venesection,
which should be practiced whenever the arterial tension is much in-
creased. With a small pulse of low tension and signs of cardiac weak-
ness it is contra-indicated. The chief difficulty is in determining whether
the apoplexy is really due to haemorrhage, or to thrombosis or embolism,
since in the latter group of cases bleeding probably does harm. As a rule,
however, in middle-aged men with arterio-sclerosis, an accentuated aortic
second sound, and hypertrophy of the left ventricle, bleeding is indicated.
Horsley and Spencer have recently, on experimental grounds, recom-
mended the practice, formerly employed empirically, of compression of
the carotid, particularly in the ingravescent form ; or even, in suitable
cases, passing a ligature round the vessel. An ice-bag may be placed on
the head and hot bottles to the feet. The bowels should be freely opened,
either by calomel, or croton oil placed on the tongue. Counter-irritation
to the neck or to the feet is not necessary. \Yhen dyspnoea, stertor, and
signs of mechanical obstruction are present, the patient should be turned
on the side, as recommended by Bowles. This procedure also lessens
the liability to congestion of the lungs.
Special care should be taken to avoid bed-sores ; and if bottles are used
to the feet, they should not be too hot, since blisters may be readily
caused by much lower temperature than in health. In the fever of reac-
tion, aconite may be indicated, but should be cautiously used. Stimu-
lants are not necessary, unless the pulse becomes feeble and signs of col-
lapse supervene.
The treatment of softening from thrombosis or embolism is very un-
satisfactory. Venesection is not indicated, as it lowers the tension and
rather promotes clotting. If, as is often the case, the heart's action is
feeble and irregular, stimulants and small doses of digitalis may be given
with, if necessary, ether or ammonia. The bowels should be kept open,
but it is not well to purge actively, as in haemorrhage.
In the thrombosis which follows syphilitic disease of the arteries, and
which is met with most frequently in men between twenty and forty (in
whom the hemiplegia often sets in without loss of consciousness), the
iodide of potassium should be freely used, giving from twenty to thirty
grains three times a day, or, if necessary, larger doses. If the syphilis has
been recent, mercurials are also indicated. Practically these are the only
cases of hemiplegia in which we see satisfactory results from treatment.
Operative treatment has been suggested, and when the diagnosis of
AFFECTIONS OP THE BLOOD-VESSELS. 883
subdural haemorrhage can be made it is justifiable. An attempt to roach
a central haemorrhage in the neighborhood of the internal capsule would
only increase the damage to the brain-substance. Very little can be done
for the hemiplegia which remains. The damage is too often irreparable
and permanent, and it is very improbable that iodide of potassium, or any
other remedy, hastens in the slightest degree Nature's dealing with the
blood-clot.
The paralyzed limbs may be gently rubbed once or twice a day, and
this should be systematically carried out, in order to maintain the nutri-
tion of the muscles and to prevent, if possible, contractures. After the
lapse of a fortnight the muscles may be stimulated by the faradic current ;
but when contractures develop, electricity is useless, and the passive move-
ments and frictions are alone indicated.
In a case of complete hemiplegia, the friends should at the outset be
frankly told that the chances of full recovery are slight. Power is
usually restored in the leg sufficient to enable the patient to get about,
but in the majority of instances the finer movements of the hand are per-
manently lost. The general health should be looked after, the bowels
regulated, and the secretions of the skin and kidneys kept active. In
permanent hemiplegia in persons above the middle period of life, more or
less mental weakness is apt to follow the attack, and the patient may be-
come irritable and emotional.
And, lastly, when hemiplegia has persisted for more than three months
and contractures have developed, it is the duty of the physician to explain
to the patient, or to his friends, that the condition is past relief, that medi-
cines and electricity will do no good, and that there is no possible hope
of cure.
Aneurism of the Cerebral Arteries.
Miliary aneurisms are not included, but reference is made only to
aneurism of the larger branches. The condition is not uncommon. There
were twelve instances in my first eight hundred autopsies in Montreal.*
This is a considerably larger proportion than in Newton Pitt's collection
from Guy's Hospital, nineteen times in nine thousand inspections.
Etiology. — Males are more frequently affected than females. Of
my twelve cases seven were males. The disease is most common at the
middle period of life. One of my cases was a lad of six. Pitt describes
one at the same age. The chief causes are (a) endarteritis, either simple
or syphilitic, which leads to weakness of the wall and dilatation ; and (b)
embolism. As pointed out by Church, these aneurisms are often found
with endocarditis. Pitt, in his recent study of the subject, concludes that
it is exceptional to find cerebral aneurism unassociated with fungating
* Canada Medical and Surgical Journal, vol. xiv.
884: DISEASES OF THE NERVOUS SYSTEM.
endocarditis. The embolus disappears, and dilatation follows the second-
ary inflammatory changes in tlie coats of the vessel.
Morbid Anatomy. — The middle cerebral branches are most fre-
quently involved. In my twelve cases the distribution on the arteries was
as follows : Internal carotid, 1 ; middle cerebral, 5 ; basilar, 3 ; anterior
communicating, 3. With the exception of one case they were saccular
and communicated with the lumen of the vessel by an orifice smaller than
the circumference of the sac. In the 154 cases which make up the statis-
tics of Lebert, Durand, and Bartholow the middle cerebral was involved
in 44, the basilar in 41, internal carotid in 23, anterior cerebral in 14, pos-
terior communicating in 8, anterior communicating in 8, vertebral in 7,
posterior cerebral in 6, inferior cerebellar in 3 (Gowers). The size of the
aneurism varies from that of a pea to that of a walnut. The haemorrhage
may be entirely meningeal with very slight laceration of the brain sub-
stance, but the bleeding may be, as Coats has shown, entirely within the
substance.
Symptoms. — The aneurism may attain considerable size and cause
no symptoms. In a majority of the cases the first intimation is the rupt-
ure and the fatal apoplexy. Distinct symptoms are most frequently caused
by aneurism of the internal carotid, which may compress the optic nerve
or the commissure, causing neuritis or paralysis of the third nerve. A
murmur may be audible on auscultation of the skull. Aneurism in this
situation may give rise to irritative and pressure symptoms at the base of
the brain or to hemianopsia. In the remarkable case reported by Weir
Mitchell and Dercum an aneurism compressed the chiasma and produced
bilateral temporal hemianopsia.
Aneurism of the vertebral or of the basilar may involve the nerves from
the fifth to the twelfth. A large sac at the termination of the basilar may
compress the third nerves or the crura.
The diagnosis is, as a rule, impossible. The larger sacs produce the
symptoms of tumor, and their rupture is usually fatal.
Endarteritis.
In no group of vessels do we more frequently see chronic degenera-
tive changes than in those of the circle of Willis. The condition oc-
curs as :
(a) Arteriosclerosis^ producing localized or diffused thickening of the
intima with the formation of atheromatous patches or areas of calcifica-
tion. In the later stages, as seen in elderly people, the arteries of the
circle of Willis may be dilated, stiff, or almost universally calcified.
{h) Syphilitic Endarteritis. — As already mentioned under the section
of syphilis, gummatous endarteritis is specially prone to attack the cere-
bral vessels. It has in itself no specific characters — that is to say, it is
impossible in given sections to pick out an endarteritis syphilitica from
AFFECTIONS OF THE BLOOD-VESSELS. 885
an ordinary endarteritis obliterans. On the other hand, as already stated,
the nodular periarteritis is never seen except in syphilis.
Thrombosis of the Cerebral Sinuses and Veins.
The condition may be primary or secondary.
Primary thrombosis of the sinuses and veins is rare. It occurs (a)
in children, particularly during the first six months of life, usually in con-
nection with diarrhcea. It has, in my experience, been a rare condition.
I have never seen an example of spontaneous thrombosis of the sinuses in
a child, and only two instances, both in connection with meningitis, in
which the cortical veins contained clots. Gowers believes that it is of fre-
quent occurrence, and that thrombosis of the veins is not an uncommon
cause of infantile hemiplegia.
(b) In connection with chlorosis and anaemia. Brayton Ball has recently
called attention to this interesting association, and has reported one case
and collected ten or eleven others from the literature. All were in girls
with anaemia or chlorosis.
(c) In the terminal stages of cancer, phthisis, and other chronic dis-
eases thrombosis may gradually occuf* in the sinuses and cortical veins.
To the coagulum developing in these conditions the term marantic throm-
bus is applied.
Secondary Thrombosis is much more frequent and follows extension
of inflammation from contiguous parts to the sinus wall. The com-
mon causes are disease of the internal ear, fracture, compression of the
sinuses by tumor, or suppurative disease outside the skull, particularly
erysipelas. In these cases the lateral sinus is most frequently involved.
Of 57 fatal cases in which ear-disease caused death with cerebral lesions,
there were 22 in which thrombosis existed in the lateral sinuses (Pitt).
The thrombus may be small, or may fill the entire sinus and extend into
the internal jugular vein. In more than one half of these instances the
thrombus was suppurating. The disease spreads directly from the necro-
sis on the posterior wall of the tympanum. It is not so common in disease
of the mastoid cells.
Symptoms. — Primary thrombosis of the longitudinal sinus may
occur without exciting symptoms and is found accidentally at the post-
mortem. There may be mental dulness with headache. Convulsions and
vomiting may occur. In other instances there is nothing distinctive. In
a patient who died under my care, at the Philadelphia Hospital, of phthisis,
there was a gradual torpor, deepening to coma, without convulsions, local-
izing symptoms, or optic neuritis. The condition was thought to be
due to a terminal meningitis. In the chlorosis cases the head symp-
toms have, as a rule, been marked. Ball's patient was dull and stupid,
had vomiting, dilatation of the pupils, and double choked disks. Slight
paresis of the left side occurred. An interesting feature in her case was
836 DISEASES OF THE NERVOUS SYSTEM.
the development of swelling of the left leg. In the cases reported by An-
drew, Church, Tuckwell, Isambard Owen, and Wilks the patients had
headache, vomiting, and delirium. Paralysis was not present. In Doug-
las Powell's case, with similar symptoms, there was loss of power on the
left side. Bristowe reports a case of great interest in an anaemic girl of
nineteen, who had convulsions, drowsiness, and vomiting. Tenderness
and swelling developed in the position of the right internal jugular vein,
and a few days later on the opposite side. The diagnosis was rendered
definite by the occurrence of phlebitis in the veins of the right leg. The
patient recovered.
The onset of such symptoms as have been mentioned in an anaemic
or chlorotic girl should lead to the suspicion of cerebral thrombosis. In
infants the diagnosis can rarely be made. Involvement of the cavernous
sinus may cause oedema about the eyelids or prominence of the eyes.
In the secondary thrombi the symptoms are commonly those of septi-
caemia. For instance, in over seventy per cent of Pitt's cases the mode of
death was by pulmonary pyaemia. This author draws the following im-
portant conclusions : (1) The disease spreads oftener from the posterior
wall of the middle ear than from the mastoid cells. (2) The otorrhoea
is generally of some standing, but n^t always. (3) The onset is sudden,
the chief symptoms being pyrexia, rigors, pains in the occipital region and
in the neck, associated with a septicaemic condition. (4) Well-marked
optic neuritis may be present. (5) The appearance of acute local pulmo-
nary mischief or of distant suppuration is almost conclusive^ of thrombosis.
(6) The average duration is about three weeks, and death is generally
from pulmonary pyaemia. The chief points in the diagnosis may be gath-
ered from these statements.
Pitt records an interesting case of recovery in a boy of ten, who had
otorrhoea for years and was admitted with fever, earache, tenderness, and
oedema. A week later he had a rigor, and optic neuritis developed on the
right side. The mastoid was explored unsuccessfully. The fever and
chills persisting, two days later the lateral sinus was explored. A mass of
foul clot was removed and the jugular vein was tied, after which the boy
made a satisfactory recovery.
AFFECTIONS OF THE SUBSTANCE.
887
III. AFFECTIONS OF THE SUBSTANCE.
I. Topical Diagnosis.
A majority of tlie lesions of the nervous system which permit of a
local diagnosis have as an important part of their symptomatology dis-
turbance of muscular action, and as our knowledge of the mechanism
governing the movements of muscles is comparatively exact, we shall
take this system as a basis for local diagnosis.
The motor system is made up of two segments, each consisting of
groups of nerve-cells, and their prolongations into nerve-fibres. The
upper segment comprises the motor cortex and the pryamidal fibres ; and
the loiuer segment the motor cells in the medulla and cord and the nerve-
fibres arising from them, forming the peripheral nerves distributed to the
muscles, which may themselves be considered as part of this segment.
The nerve-cells are so arranged that when thrown into action, by
whatever cause, a definite movement is the result, and the same combina-
tion of nerve-cells always causes the same movement, or, in other words,
every movement of the body is represented in the nervous centres by com-
binations of the nerve-cells, or, as we say, is localized.
Movements are localized both in the cells of the lower segment and in
those of the upper, and we have consequently spinal localization and cere-
bral localization.
Spinal Lobalization. — In the lower motor segment the muscles are
represented in their simplest movements, and different sections of the cord
have been found to represent the movements of different muscles. Our
knowledge of this localization is by no means complete, but enough has
been learned to aid us materially in determining the site of a spinal le-
sion.
The cells of the lower segment are found in the motor nuclei of the
medulla, and in the anterior gray horns of the spinal cord. They are con-
nected with the muscles by the axis cylinder processes, the anterior nerve-
roots (roots of motor cranial nerves), the peripheral nerves, and the end
organs by which they are brought into intimate relation with the proto-
plasm of the muscle fibre itself.
The following table prepared by Starr gives in detail our knowledge
on this subject :
Localization of the Functions of the Segments of the Spinal Cord.
Segment.
Muscles.
Reflex.
Sensation.
II and
III C.
Storrio-mastoid.
Trapezius.
Scalcrii and neck.
Diaphragm.
Ilypchondrium (?),
Sudden inspiration pro-
duced by sudden press-
ure beneath the lower
border of ribs.
Baek of head to ver-
tex.
Neck.
888
DISEASES OF THE NERVOUS SYSTEM.
Segment,
Muscles.
Reflex.
Sensation.
IV C.
Diapliragm.
Pupil. 4th to 7th cer-
Neck.
Deltoid.
vical.
Upper shoulder.
Biceps.
Dilatation of the pupil
Outer arm.
Coraco-brachialis.
produced by irritation
Supinator longus.
of neck.
Rhomboid.
Supra and infra spinatus.
V C.
Deltoid.
Scapular.
Back of shoulder and
Biceps.
5th cervical to 1st dorsal.
arm.
Coraco-brachial is.
Irritation of skin over the
Outer side of arm
Brachialis anticus.
scapula produces con-
and forearm, front
Supinator longus.
traction of the scapular
and back.
Supinator brevis.
muscles.
Rhomboid.
Supinator longus.
Teres minor.
Tapping its tendon in
Pectoralis(clavicular part).
wrist produces flexion
Serratus magnus.
of forearm.
VI c.
Biceps.
Triceps.
Outer side of fore-
Brachialis anticus.
5th to 6th cervical.
arm, front and
Pectoralis(clavicular part).
Tapping elbow tendon
back.
Serratus magnus.
produces extension of
Outer half of hand.
Triceps.
forearm.
Extensors of wrist and
Posterior wrist.
fingers.
6th to 8th cervical.
Pronators.
Tapping tendons causes
extension of hand.
VII c.
Triceps (long head).
Anterior wrist.
Inner side and back
Extensors of wrist and
7th to 8th cervical.
of arm and fore-
fingers.
Tapping anterior tendons
ann.
Pronators of wrist.
causes flexion of wrist.
Radial half ot the
Flexors of wrist.
Palmar. 7th cervical to
hand.
Subscapular.
1st dorsal.
Pectoralis (costal part).
Stroking palm causes
Latisimus dorsi.
closure of fingers.
Teres major.
VIII c.
Flexors of wrist and fin-
Forearm and hand,
gers.
inner half.
Intrinsic muscles of hand.
I D.
Extensors of thumb.
Forearm, inner half.
Intrinsic hand muscles.
Ulnar distribution to
Thenar and hypothenar
hand.
eminences.
II to
Muscles of back and abdo-
Epigastric. 4th to 7th
Skin of chest and
XII D.
men.
dorsal.
abdomen in bands
Erectores spina).
Tickling mammary re-
running around
gions causes retraction
and downward, cor-
of epigastrium.
responding to spi-
Abdominal. 7th to 11th
nal nerves.
dorsal.
Upper gluteal region.
Stroking side of abdomen
causes retraction of
belly.
I L.
Ilio-psoas!
Cremasteric. 1st to 3d
Skin over groin and
Sartorius.
lumbar.
front of scrotum.
Muscles of abdomen.
Stroking inner thigh
causes retraction of
scrotum.
AFFECTIONS OF THE SUBSTANCE.
889
Segment.
Muscles.
Reflex.
Sensation.
II L.
Ilio-psoas. Sartorius.
Flexors of knee (Remak).
Quadriceps feraoris.
Patella tendon.
Stroking tendon causes
extension of leg.
Outer side of thigh.
Ill L.
Quadriceps femoris.
Inner rotators of thigh.
Abductors of thigh.
Front and inner side
of thigh.
IV L.
Abductors of thigh.
Adductors of thigh.
Flexors of knee (Ferrier).
Tibialis anticus.
Gluteal. 4th to 5th lum-
bar.
Stroking buttock causes
dimpling in fold of
buttock.
Inner side of thigh
and leg to ankle.
Inner side of foot.
V L.
Outward rotators of thigh.
Flexors of knee (Ferrier).
Flexors of ankle.
Extensors of toes.
Back of thigh, back
of leg, and outer
part of foot.
I to 11
S.
Flexors of ankle.
Long flexor of toes.
Peronaei.
Intrinsic muscles of foot.
Plantar.
Tickling sole of foot
causes flexion of toes
and retraction of leg.
Back of thigh.
Leg and foot, outer
side.
Ill to
V s.
Perineal muscles.
Foot reflex. Achilles
tendon.
Overextension of foot
causes rapid flexion ;
ankle-clonus.
Bladder and rectal centres.
Skin over sacrum.
Anus.
Perinaeum. Genitals.
Cerebral Motor Localization. — In the motor cortex the muscles are
again represented, or, as Hughlings Jackson says, re-represented in their
finer movements.
Motor Centres. — The experiments of Hitzig and Fritsch and of Fer-
rier, together with the previous clinical studies of Hughlings Jackson,
laid the foundation of our present knowledge of cerebral localization.
The area for representation of the movements in the cerebral cortex is
in the Rolandic region and comprises the ascending parietal and ascending
frontal convolutions, the hinder part of the three frontal convolutions, and
the parietal lobule, a continuation backward of the ascending parietal
convolution (Fig. 2, motor region). This entire region is excitable, and
stimulation by weak electrical currents produces muscular movements in
the opposite half of the body. The centres presiding over the different
groups of muscles may be thus classified :
{a) Centres for the trunk. These have been shown by Schafer to be
situated in the marginal gyrus, just within the longitudinal fissure, the
region sometimes spoken of as the paracental lobule.
(h) Centres for the lower limbs. These are situated at the upper part
of the Rolandic region, close to the longitudinal fissure. As indicated in
the diagram, the representation of movements of the different portions of
the lower limb in this region is as follows (Fig. 2) : Most anterior, the
hip ; next in order, the knee and ankle ; then the big toe, the centre for
890
DISEASES OF THE NERVOUS SYSTEM.
the movement of which surrounds the upper end of the fissure of Rolando.
Still further back are the centres for movement of the small toes.
(c) Centres for the upper limbs. This area corresponds to about the
Fig. 2. — (After Mills). This diagram approximately indicates the views now held as a
result of experiment and their confirmation or modification by clinico-pathological
observation. It represents the division of the lateral surface of the cerebrum into
Inghcr psychical, motor, sensory, visual, and auditory areas ; also the subdivision of
the motor area into subareas for speech, the head and eyes, the face, arm, leg, and
trunk. Only certain main points have been indicated by lettering, so as not to
confuse: S, fissure of Sylvius; li, fissure of Rolando, or central fissure; Fc, pre-
central fissure; Be, retrocentral fissure; Fl, F2^ superior and inferior frontal fis-
sure ; 7/7, interparietal fissure ; Po, parieto-occipital fissure ; Tl, first temporal
fissure.
AFFECTIONS OF THE SUBSTANCE. 891
middle two fourths of the motor iircii. The careful studies of Ilorsley
and Beevor have shown that from above downward the different segments
of the limbs are represented as follows : Shoulder, elbow, wrist, fingers,
the index-finger, and, lowest of all, the thumb.
(d) The centres for the face, tongue, pharynx, and larynx are situated
in the lowest portion of the Eolandic area. The centres for tlie movement
of the tongue and vocal cords are in the lower and anterior portion of the
ascending convolution, and on the left side in man this region and the
posterior part of the third left frontal convolution constitute the speech
centre (Fig. 2), destruction of which is followed by one form of aphasia.
In front of the precentral sulcus are centres for the representation of
movements for turning the head and eyes to the opposite side.
The determination of these areas was worked out in animals and has
now been thoroughly established in man, both by clinical observation and
by the application of the electrodes in different situations during opera-
tions for the removal of growths in the brain or of the motor centres in
epilepsy. The different regions must not be regarded as sharply separated
from, but as blending with each other.
With these centres for voluntary movements are associated those which
preside over the muscular sense, which is a compound of sensory im-
pressions, of pressure, tension, and touch derived from the muscles as they
are in motion. There is still dispute with reference to the localization of
this sense, but the general opinion is that lesions of the motor area itself
cause slight loss both of muscular and tactile sense. Others place the cen-
tres for general sensation in the situation marked in Fig. 2.
The fibres uniting the cortical motor centres and the spinal centres
have a long course, in which they probably have no connection with any
other nerve-cells. They arise from the various centres, enter the white
matter of the hemisphere (the corona radiata), and gradually converge to
what is called the internal capsule, which lies between the lenticular nucleus
and the thalamus and the caudate nucleus (Fig. 3). The position of the fibres
in the internal capsule has been accurately worked out by several observ^
ers. The fibres from the centres of the face, tongue, eyes, and head occupy
the most anterior position, just at the knee, as it is called, of the internal
capsule, while the fibres from the upper extremities are just behind these,
and those from the lower extremities occupy the position in the middle
third of the posterior part. Leaving the internal capsule, the fibres form-
ing the motor path pass from the brain into the crus, in which they oc-
cupy a lower and medial position. Passing through the pons, covered by
the superficial layers of transverse fibres, they enter the medulla, of which
they form the anterior or pyramidal tract. At the lower part of the
medulla a large proportion of the fibres decussate and pass into the oppo-
site side of the spinal cord, forming the crossed pyramidal tract of the
lateral column, while a smaller number of the fibres descend in the an-
terior column of the same side, forming the direct pyramidal tract, or
892
DISEASES OF THE NERVOUS SYSTEM.
Tiirck's column. The pyramidal tracts diminish in size from above
downward. The fibres enter the gray matter between the anterior and
^S^'ft^k'^-^^^osssD PyaAMiDAL Fibres
^Direct Pyramid/kl Fibres
Fio. 3.— Motor Tract (after Starr). S, fissure of Sylvius ; NL, lenticular nucleus ;
OT, optic thalamus ; 0, olivary body. The tracts for the face, arm, and leg gather
in the capsule and pass together to the lower pons, where the face-fibres cross to
the opposite VII nerve nucleus, while the others pass on to the lower medulla,
where they partially decussate to enter the lateral columns of the cord ; the non-
decussating fibres pass to the anterior median columns. The effect of a lesion
situated at three points in the tract is shown on the left side of the figure at X,
Y, Z. At Z the lesion would involve the left facial nerve and the left pyramidal
tract above the decussation, producing facial paralysis on the left side and paralysis
of the arm and leg on the opposite side — crossed paralysis.
posterior cornua, pass forward, divide and subdivide, and finally join the
plexus of the protoplasmic processes, and are in this way connected with
the large nerve-cells of the anterior horns.
Lesions of the Motor System. — Each of the segments of the motor
tract is to be considered as a nutritional unit, depending for its vitality
upon the integrity of its ganglion cells. If certain cells in the cortex are
destroyed, the fibres arising from them will degenerate throughout their
length — that is, to the beginning of the lower motor segment. So also if
the motor cells in the medulla or cord are injured, their nerve-fibres will
degenerate, and the muscles to which they are distributed will also be
involved in the process. The same thing occurs if the nerve-fibres become
detached from their ganglion cells. This process is called secondary
AFFECTIONS OF THE SUBSTANCE.
893
degeneration or Wallerian degeneration, after the physician wlio first de-
scribed it. Fig. 4 illustrates this process in the cortico-spinal motor seg-
ment.
The lesions may be grouped, as Ilughlings Jackson suggested, into
negative and positive, or, as they are now more
usually termed, destructive and irritative.
Negative or destructive lesions anywhere in
the motor path have as a result the abolishment
of the functions of these parts — i. q.^ paralysis.
Positive or irritative lesions cause a perver-
sion of the function — i. e., abnormal muscular
contractions.
Although these two symptoms (paralysis and
abnormal contractions) occur whenever the mo-
tor path is diseased, each of the segments im-
parts to them peculiar characteristics which en-
able us in a great majority of cases to determine
the site of a lesion.
These characteristics depend upon, first, the
special symptoms referable to the secondary de-
generations in the two segments; second, upon
their anatomical relation.
{a) Lesions of the Lower or Spino-muscular
Segment. Destructive Lesions. — The destructive
lesions cause here, as everywhere in the motor
path, paralysis. We have seen above that when
the nerve-fibres are cut off from their ganglion
cells in the anterior horns, they not only degen-
erate themselves, but that the muscles to which
they are distributed degenerate. This process is
made evident by a change in the electrical reac-
tion of the nerve and muscle — the reaction of
degeneration — and the muscle becomes evident-
ly atrophied. The myotatic irritability or mus-
cle reflex, which depends upon the integrity of
the lower motor segment, is lost in destructive
lesions. This gives to the paralysis certain characteristics, namely, atro-
phy of the muscles, loss of its reflex excitability, and alteration of the
electrical reactions of the nerve and muscle.
The anatomical relations of the lower motor segment also give certain
peculiarities, which help to distinguish its lesions from those of the upper
segment, on the one hand, and of the different parts of the lower segment
on the other.
In general the different units which make up the lower segment are
more or less widely separated from each other. An extreme example of
Fig. 4
(After Gowers.)
Diagram showing course
and degeneration of pyr-
amidal tract in right
hemisphere, crus, pons
medulla, and cord.
894: DISEASES OF THE NERVOUS SYSTEM.
tliis is the distance between the nucleus of the third nerve and the collec-
tion of motor cells in the lower part of the lumbar enlargement. For this
reason lesions of this segment are more apt to cause paralysis of individual
muscles or muscle groups, as distinguished from the more wide-spread
paralysis due to lesions of the upper segment.
Reference to Starr's table will show that the muscles are represented
in the spinal cord without relation to the nerves which supply them — that
is to say, muscles that are supplied by a certain nerve may not be repre-
sented close together in the anterior horns ; for instance, in the fourth
cervical segment, movements of the diaphragm, deltoid, biceps, supinator
longus, rhomboid, supraspinatus, and infraspinatus are represented. It fol-
lows from this that the distribution of a paralysis due to disease of the lower
motoi segment may enable us to distinguish the position of the lesion
within the segment itself. We are often helped in this by the sensory
symptoms, Avhich may accompany the paralysis. Thus, if we have a paral-
ysis with the characteristics of a lesion of the lower motor segment, and
if the paralyzed muscles are all supplied by one nerve, and we discover
anaesthesia in the skin of the arm supplied by that nerve, it is evident
that the lesions must be in the nerve itself. On the other hand, if the
muscles paralyzed are not supplied by a single nerve, but are represented
close together in the spinal cord, and the anaesthesia corresponds to that
section of the cord (see table), it is equally clear that the lesion must be of
the cord itself or of its nerve-roots.
Irritative Lesions of the Loioer Motor Segment. — AYe know of no lesion
of this segment which has as its result abnormal muscular contraction
unless the slow atrophy of the ganglion cells occurring in progressive mus-
cular atrophy be considered as the cause of the fibrillary contraction so
common in this affection.
(Certain tonic muscular contractions occurring in poisoning by strych-
nine and in tetanus are thought to be due to the perverted action of the
lower motor centres, and Hughlings Jackson believes that certain convul-
sive paroxysms — " lowest level fits " — are due to discharging lesions of these
centres, and claims laryngismus stridulus in this category.)
{b) Lesions of the Upper, Cerebro-spinal Motor Segment. — Destructive
lesions cause, as in the lower motor segment, paralysis, and here again the
secondary degeneration which follows the lesion gives to the paralysis its
distinctive characteristics. In this case the paralysis is accompanied by a
spastic condition, shown in an exaggeration of muscle reflex and an in-
crease in the tension of the muscle. It is not accurately known how the
degeneration of the pyramidal fibres causes this excess of the muscle
reflex. The usual explanation is that under normal circumstances the
upper motor centres are constantly exerting a restraining influence upon
the activity of the lower centres, and that when the influence ceases to act,
on account of disease of the pyramidal fibres, the latter take on increased
activity, which is made manifest by an exaggeration of the muscle reflex.
AFFECTIONS OF THE SUBSTANCE. 895
It was stated above that each segment of the motor path is to be con-
sidered as a nutritional unit and that the secondary degeneration in the
upper segment stops at the beginning of the lower. So the muscles para-
lyzed by lesions in the upper segment do not undergo degenerative
atrophy, nor do they present the reaction of degeneration.
The upper motor segment is much more compact than the lower, and
for this reason a paralysis resulting from a lesion in it is apt to involve
many muscles. This is especially true in regard to the pyramidal fibres,
which run in a compact bundle, a lesion of which usually involves all of
the fibres and causes a paralysis of all of the muscles of one side of the
body — i. e., hemiplegia.
The motor centres of the cortex are more or less separated from each
other, and a sharply localized lesion in this region causes a more limited
paralysis, and cerebral monoplegias are the result ; but even in this case the
paralysis is diffuse, affecting the whole limb or a segment of the limb, and
not individual muscles or groups of muscles.
To sum up, the paralyses due to lesions of the cerebro-spinal motor
segment are diffuse, wide-spread, often hemiplegic ; the paralyzed muscles
are spastic (the tendon reflexes exaggerated), they do not undergo degen-
erative atrophy, and they do not present the degenerative reaction to elec-
trical stimulation.
Irritative Lesions of the Upper Motor Segment. — Our knowledge of
such lesions is confined for the most part to those acting on the cortical
motor centres, and we know a number of processes which have as their
result abnormal muscular contractions. These have as their type the local-
ized convulsive seizures classed under Jacksonian or cortical epilepsy, which
are characterized by the convulsion beginning in a single muscle or group
of muscles and involving other muscles in a definite order, depending upon
the position of their representation in the cortex ; for instance, such a con-
vulsion beginning in the muscles of the face next involves those of the arm
and hand, and then the leg. The convulsion is usually accompanied by
sensory phenomena and followed by a weakness of the muscles involved.
A majority of lesions of the motor cortex are both destructive and irri-
tative— i. e., they may destroy the nerve-cells of a certain centre, and either
by their growth or presence may throw into abnormal activity those of the
surrounding centres.
So far the motor system has been considered by itself, and we have
endeavored to show how attention to the paralysis alone may help us to
determine the seat of a lesion. It runs, however, in close connection with
other systems of the nervous centre, which are often involved with it in
morbid processes, giving rise to symptoms which aid us very much in
making a local diagnosis.
Sensory Centres and Paths. — The association of the motor path with
that for the conduction of sensory impresc;ions is very intimate, but unfor-
tunately our knowledge of the exact position of the sensory tracts is by
896 DISEASES OF THE NERVOUS SYSTEM.
no means so precise. Some important facts are, however, known. Sensory
fibres from different areas of the skin run in close connection with fibres
of the lower motor segment in the mixed nerves. They separate from
them and enter the spinal cord by the posterior roots. The regions which
the different posterior roots supply is given in Starr's table. After enter-
ing the spinal cord the sensory fibres cross the middle line at once and
pass up to the brain in the opposite half of the cord. Here they are again
in close contact with the motor path, but with that of the other side of the
body — i. e., the right half of the spinal cord contains the sensory fibres of
the left side of the body and motor fibres of the right. The fibres which
conduct the impressions for the muscular sense seem to be an exception
and do not decussate in the cord. The exact position of the sensory paths
in the cord is still somewhat uncertain, nor are we sure of their course in
the medulla, pons, and peduncle. All the sensory fibres of the opposite
side of the body are collected in the posterior third of the posterior limb
of the internal capsule, just behind the motor fibres of the upper segment.
Much doubt and discussion still exist as to the areas for the represen-
tation of sensory impressions. Horsley has suggested that the muscular
and tactile senses are localized in the motor cortex, and that two of the
three chief layers of cells in this region subserve their functions. Dana's
study shows that many lesions of the motor area, particularly in the hinder
part, are associated with anaesthesia. On the other hand. Terrier regards
the hippocampal convolution, and Schiifer the gyrus formicatus, as the
centres for sensory impressions.
The centres for sight, hearing, smell, and taste have been referred to
under the nerves ministering to these senses, and we shall consider the
speech centres in the next section.
In the centrum ovale the fibres of the motor path are more or less
closely associated with other systems of fibres ; those connecting the cor-
tex with nervous structures lying below it, projection fibres ; the fibres
which join the two hemispheres, commissural fibres ; and those which join
different parts of the same hemisphere, association fibres. Our knowledge
of the function of these fibres leaves much to be desired.*
The following is a brief summary of the effects of lesions from the
cortex to the spinal cord :
1. The Cerebral Cortex. — (a) BestYuctiye lesions cause spastic pai-aly-
sis in the muscles of the opposite side of the body. The extent of the
paralysis depends upon that of the lesion. It is apt to be limited to the
muscles of an extremity, giving rise to the cerebral monoplegias (Fig.
3, X). A lesion may involve two centres lying close together, thus pro-
ducing paralysis of the face and arm, or of the arm and leg, but not of
* The student will find in Starr's work, Familiar Forms of Nervous Disease, an
admirable presentation of this subject.
AFFECTIONS OF THE SUBSTANCE. 897
the face and leg without involvement of the arm. Very rarely the whole
motor cortex is involved, causing paralysis of one side — cortical hemi-
plegia.
Combined with the muscular weakness there is usually some disturb-
ance of sensation, particularly tactile impressions and those of the mus-
cular sense.
(b) Irritative lesions cause localized spasms as described above. These
convulsions are usually preceded and accompanied by sensory impressions.
Tingling or pain, or a sense of motion in the part, is often the signal
symptom (Seguin), and is of great importance in determining the seat of
the lesion.
Lesions are often both destructive and irritative, and we have combi-
nations of the symptoms produced by each. For instance, certain muscles
may be paralyzed, and those represented near them in the cortex may be
the seat of localized convulsions, or the paralyzed limb itself may be at
times subject to convulsive spasms, or muscles which have been convulsed
may become paralyzed. In this manner it is often possible to trace the
progress of a lesion involving the motor cortex.
We have seen in a previous section that lesions involving the centres
for the special senses may give rise to focal symptoms, and shall simply
refer to them here. The symptoms caused by lesions of the speech centre
will be described under aphasia, and it is only necessary to note the near
situation of the motor speech area (Broca's centre) in the left third
frontal convolution to the centres of the face and arm on that side, and to
state that motor aphasia is often associated with monoplegia of the right
side of the face and the right arm. Accompanying the paralysis follow-
ing a Jacksonian fit of the right face or arm there is often a transient
motor aphasia.
(2) Centrum Ovale. — Lesions in this part of the motor path cause
paralysis, which has the distribution of a cortical palsy when the lesion is
near the cortex, and of that due to a lesion of the internal capsule when
it is near that region. They may be associated with symptoms due to the
interruption of the other system of fibres running in the centrum ovale,
and there may be sensory disturbances — hemianaesthesia and hemianopia —
and if the lesion is in the left hemisphere one of the different forms of
aphasia may accompany the paralysis.
(3) Internal Capsule. — Here all the fibres of the upper motor segment
are gathered together in a compact bundle, and a lesion in this region is
apt to cause complete hemiplegia of the opposite side, and if the lesion
involves the hinder third of the posterior limb there is also hemianaesthe-
sia, including even the special senses(Fig. 3, Y).
(4) Crura Cerebri. — Here, again, all the motor fibres and all the
sensory fibres of tlie opposite side are collected in a small space, and a
lesion may produce hemiplegia combined with sensory disturbances. On
account of its anatomical relation the third cranial nerve is often involved
898 DISEASES OF THE NERVOUS SYSTEM.
in lesions of the cms, causing paralysis of the muscles of the eye on the
same side as the lesion combined with a hemiplegia of the opposite side —
i. e., a crossed paralysis.
(5) Pons. — In the pons, medulla, and cord the upper and lower motor
segments are both represented, the first by the pyramidal fibres, the latter
by the motor nuclei and the nerve-fibres arising from them. Lesions here
often affect both motor segments, and produce combinations of paralyses
having the characteristics of each. Thus a lesion in the lower part of the
pons may involve the pyramidal tract and cause a spastic paralysis of the
opposite arm and leg, and also involve the nucleus or the fibres of the
facial nerve, and so produce a paralysis of the same side of the face, accom-
panied by loss of the muscle reflex, atrophy, and the reaction of degen-
eration— crossed paralysis (Fig. 3, Z). The abducens and hypoglossus
nerves may also be paralyzed in the same manner. In lesions of the
pons the patient often has a tendency to fall toward the side on which
the lesion is, due probably to implication of the middle peduncle of the
cerebellum.
The symptoms produced by involvement of the different cranial nerves
have been considered in detail in a previous section.
(6) Spinal Cord. — Unilateral lesions cause, first, a lower-segment pa-
ralysis, due to the disease of the centres at the site involved ; second, a
spastic paralysis of all the muscles on that side of the body below the
lesion, due to interruption of the pjTamidal fibres ; and, third, disturbance
of sensation in the opposite side of the body. (See under Brown-Sequard's
paralysis.)
Transverse lesions of the cord cause paralysis with atrophy, etc., at the
level of the lesion, spastic paralysis below it, combined with sensory dis-
turbance and trouble with the bladder and rectum.
Affections of the peripheral nerves have already been considered.
II. Aphasia.
The speech mechanism consists of receptive, perceptive, and emissive
centres in the cortex cerebri, disturbances of which cause aphasia^ and
centres in the medulla which preside over the muscles of articulation, dis-
turbance of which produces anarthria, the condition of gradual loss of
power of speech, such as occurs in bulbar paralysis.
The studies of Bastian, Kiissmaul, Wernicke, Lichtheim, and others
have widened enormously our knowledge of speech disorders. Language
is gradually acquired by imitation. Thus, in teaching a child to say bell^
the sound of the uttered word enters the afferent path (auditory nerve)
and reaches the auditory perceptive centre, from which an impulse is sent
to the emissive or motor centre presiding over the nuclei in the medulla,
through which the muscles of articulation are set in action. The arc
in Lichtheim's schema (Fig. 5) is a A, Mm. The child gradually ac-
AFFECTIONS OF THE SUBSTANCE.
899
h m
Fig. 5. — Lichtheim's schema.
quires in this way word memories^ which are stored at the centre A, and
motor me77iories — the memories of the co-ordinated muscular movements
necessary to utter words — which are stored at the centre M. In a similar
manner, when shown the bell, the child acquires visual memories, which
are conveyed through the optic
nerve to the visual perceptive
centres, o 0. So also the memo-
ries of the sound of the bell
when struck. The memory pict-
ure of the shape of the bell, the
memory of the appearance of the
word bell as written, and the
motor memories of the muscular
movements required to write the
word are distinct from each
other ; yet they are intimately
connected, and form together
what is termed the word-image.
In addition to all this the child
gradually acquires in his education ideas as to the use of the bell —
intellectual concepts — the centre for which is represented at I in the
diagram In volitional or intellectual speech, as in uttering the word
hell, the path would be I, M m, and in writing the word, I, M, AY, h.
These various " memories " are as a rule stored or centred in the left
hemisphere.
The relations of written and spoken language are then with {a) sen-
sory perceptive centres (hearing and sight and, in the blind, touch) ; {b)
emissive or motor centres for speech and writing ; and {c) psychical cen-
tres, through which we obtain an intellectual conception of what is
said or written, and by which we express voluntarily our ideas in lan-
guage.
There are two chief forms of aphasia — sensory and motor.
(1) Sensory Aphasia; Apraxia; Word-blindness; Word-deafness.— By
apraxia is understood a condition in which there is loss or impairment of
the power to recognize the nature and characteristics of objects. Persons so
affected act " as if they no longer possessed such object memories, for they
fail to recognize things formerly familiar. A fork, a cane, a pin, may be
taken up and looked at by such a person, and yet held or used in a manner
which clearly shows that it awakens no idea of its use. And this symp-
tom, for which at first the term blindness of mind was used, is found to
extend to other senses than that of sight. Thus the tick of a watch, the
sound of a bell, a melody of music, may fail to arouse the idea which it
formerly awakened, and the patient has then deafness of mind, or an
odor or taste no longer calls up the notion of the thing smelled or
tasted ; and thus it is found that each or all of the sensory organs, when
67
900 DISEASES OF THE NERVOUS SYSTEM.
called into play, may fail to arouse an intelligent perception of the
object exciting them. For the general symptoms of inability to recog-
nize the use or import of an object the term apraxia is now employed."
(Starr.)
Apraxia may occur alone, but more commonly is associated with varie-
ties of sensory and motor aphasia. The patient may be able to read, but
the words arouse no intelligent impression in his mind. While blind to
memory-pictures aroused through sight, the perceptions may be stimu-
lated by touch ; thus there are instances on record of apraxic patients un-
able to read by sight, who could on tracing the letters by touch name
them correctly. Of the forms of apraxia, mind-blindness and mind-
deafness are the most important.
The cases of mind-hlindness collected by Starr indicate that the lesion
exists in the left hemisphere in right-handed persons, and in the right
hemisphere in left-handed persons. The disease usually involves the
angular and supramarginal gyri or the tracts proceeding from them.
Blindness of the " mind's eye " may at times be functional and transitory,
and is associated with many forms of mental disturbance. In a remark-
able case reported by Mace wen, the patient, after an injury to the head,
had suffered with headache and melancholia, but there was no paralysis.
He was psychically blind and though he could see everything perfectly
well and could read letters, objects conveyed no intelligent impression.
A man before his eyes was recognized as some object, but not as a man
until the sounds of the voice led to the recognition through the auditory
centres. The skull was trephined over the angular gyrus and the inner
table was found to be depressed and a portion had been driven into the
brain in this region. The patient recovered. Mind-blindness is the equiva-
lent of visual amnesia.
Word-blindness may occur alone or with motor aphasia. In un-
complicated cq-ses the patient is no longer able to recall the appear-
ances of words, and does not recognize them on a printed or written
page. Tlie patient may be able to pronounce the letters and can
often write correctly, but he cannot read understandingly what he has
written. It is rare, however, for the patient to be able to write with
any degree of facility. There are instances in which the patient, un-
able to read, has yet been able to do mathematical problems and to
recognize play cards. The lesion in cases of word-blindness is, in a
majority of cases, in the angular and supramarginal gyri on the left side.
It is commonly associaX;ed with hemianopia, and not infrequently with
mind-blindness.
Mind-deafness is a condition in which sounds, though heard and per-
ceived as such, awaken no intelligent conceptions. A person who knows
nothing of French has mind-deafness so far as the French language is
concerned, and though he recognizes the words as words when spoken,
and can repeat them, they awaken no auditory memories. The musical
AFFECTIONS OF THE SUBSTANCE. 901
faculties may be lost in apliasics, who may become note-deaf and unable
to appreciate melodies or to read music. Tliis may occur without tlie
existence of motor aphasia, and on the other hand there are cases on
record in wliich with motor aphasia for ordinary speech the patient could
sing and follow tunes correctly. Mind-deafness is also known as auditory
amnesia. AVord-deafness is a condition in which the patient no longer
understands spoken language. The memory of the sound of the word
is lost, and can neither be recalled nor recognized when heard. It is usu-
ally associated with other varieties of aphasia, though there are cases in
which the patient has been able to read and write and speak. The lesion
in word-deafness has been accurately defined in a number of cases to be in
the posterior portion of the first and second temporal convolutions on the
left side (Fig. 2).
Other manifestations of mind-blindness are met with ; thus a young
man with secondary syphilis had several convulsive seizures, after one of
which he remained unconscious for some time. On awakening, the mem-
ory-pictures of faces and places were a blank, and he neither knew his
parents nor brothers, nor the streets of the town in which he lived. He
had no aphasia proper, and no paralysis.
(2) Motor or ataxic aphasia is a condition in which the memory of
the efforts necessary to pronounce words is lost, owing to disturbance
in the emissive centres. This is the variety long ago recognized by
Broca, the lesion of which was localized by him in the third left frontal
convolution. In pure cases the patient is able to read (not aloud) and
understands perfectly what is said. He may not be able to utter a
single word ; more commonly he can say one or two words, such as
"no," "yes," and he not infrequently is able to repeat words. When
shown an object, though not able to name it, he may evidently recog-
nize what it is. If told the name, he may be able to repeat it. A man
knowing the French and German languages may lose the power of ex-
pressing his thoughts in them, while retaining his mother-tongue; or,
if completely aphasic, may recover one before the other. As the third
left frontal convolution is in close contact with the centres for the face
and arm, these are not uncommonly involved, with the production of a
partial or, in some instances, a complete right-sided hemiplegia. Alexia^
or inability to read, occurs with motor aphasia and also with word-
blindness.
As a rule, in motor aphasia there is also inability to write —
agraphia. When there is right brachial monoplegia it is difficult to
test the capability, but there are instances of motor aphasia without
paralysis, in which the power of voluntary writing is lost. The con-
dition varies very much ; thus a patient may not be able to write
voluntarily or from dictation, and yet may copy perfectly. It is still
a question whether there is a special writing centre. It has been placed
by some writers at the base of the second frontal convolution, but in a
902 DISEASES OF THE NERVOUS SYSTEM.
recent study Dejerine concludes that it is not separate from the speech
centre.
There is a form known as mixed aphasia^ or ^^crr/7;;7m5m, in which
tlie patient understands what is said, and speaks even long sentences
correctly, but he constantly tends to misplace words, and does not
express his ideas in the proper words. All grades of this may be met
with, from a state in which only a word or two is misplaced to an
extreme condition in which the patient talks jargon. In these cases
the association tract is interrupted between the auditory perceptive
and the emissive centres, hence it is sometimes known as Wernicke's
aphasia of conduction. The lesion is usually in the insula and in the
convolutions which unite the frontal and temporal lobes. Lichtheim's
schema wdll assist the student in obtaining a rational idea of the varieties
of aphasia :
1. In the condition of apraxia or mind-blindness the ideation centres,
I, are involved, often with the auditory and visual perceptive centres j A
andO.
2. A lesion at A, the centre for the auditory memories of words (first
left temporal gyrus), is associated with word-deafness.
3. A lesion at 0, the centre for visual memories (angular and supra-
marginal gyri), causes word-blindness.
4. Interruption of the tracts uniting A M and 0 M causes the conduc-
tion aphasia of "Wernicke — paraphasia.
5. Destruction of the centre M (Broca's convolution) causes pure
motor aphasia, in which the patient cannot express thoughts in
speech.
A lesion at M usually destroys also the power of writing, but, as
stated, it is believed by many that the centre for writing, AV, is distinct
from that of speech. In this case a lesion at M, which would destroy
the power of voluntary speech, might leave open the connections be-
tween 0 W and A W, by which the patient could copy or write from
dictation.
The problems of aphasia are in reality excessively complicated, and
the student must not for a moment suppose that cases are as simple
as diagrams indicate. A majority of them are very complex, but with
patience the diagnosis of the different varieties can often be worked
out.
The following tests should be applied in each case of aphasia : (1) The
power of recognizing the nature, uses, and relations of objects — i. e.,
whether apraxia is present or not; (2) the power to recall the name of
familiar objects seen, smelled, or tasted, or of a sound when heard, or
of an object touched; (3) the power to understand spoken words; (4)
the capability of understanding printed or written language ; (5) the
power of appreciating and understanding musical tunes ; ((5) the power of
voluntary speech — in this it is to be noted particularly whether he mis-
AFFECTIONS OF THE SUBSTANCE 903
places words or not ; (7) the power of reading aloud and of understanding
what he reads ; (8) the power to write voluntarily and of reading what he
has written ; (9) the power to copy ; (10) the power to write at dictation ;
and (11) the power of repeating words.
Prognosis and Treatment. — In young persons the outlook is good,
and the power of speech is gradually restored apparently by the education
of the centres on the opposite side of the brain. In adults the condition
is less hopeful, particularly in the cases of complete motor aphasia with
right hemiplegia. The patient may remain speechless, though capable
of understanding everything, and attempts at re-education may be futile.
Partial recovery may occur, and the patient may be able to talk, but mis-
places words. In sensory aphasia the condition may be only transient, and
the different forms rarely persist alone without impairment of the powers
of expression.
The education of an aphasic person requires the greatest care and
patience, particularly if, as so often happens, he is emotional and irritable.
It is best to begin by the use of detached letters, and advance, not too
rapidly, to words of only one syllable. Children often make rapid progress,
but in adults failure is only two frequent, even after the most pains-taking
efforts. In the cases of right hemiplegia with aphasia the patient may be
taught to write with the left hand.
III. Inflammation of the Brain
{Suppurative Encephalitis ; Abscess).
Etiology. — Suppuration of the brain substance is rarely if ever pri-
mary, but results, as a rule, from extension of inflammation from neigh-
boring parts or infection from a distance through the blood. The question
of idiopathic brain abscess need scarcely be considered, though occasion-
ally instances occur in which it is extremely difficult to assign a cause.
There are three important etiological factors :
(1) Trauma. Falls upon the head or blows, with or without abra-
sion of the skin. More commonly it follows fracture or punctured
wounds. In this group meningitis is frequently associated with the
abscess.
(2) Extension of the inflammation from the neighboring parts, more
particularly in caries of the petrous portion of the temporal bone, less
frequently necrosis of the other bones, or extension of disease from the
orbit. In this group otitis is the most important factor. There may
be extension through the bone and involvement of the lateral sinus
as already mentioned ; but in other instances no direct connection can
be traced and the infection is probably carried through the lymph
channels.
(3) In septic processes. Abscess of the brain is not often found in
pyafimia. In ulcerative endocarditis multiple foci of suppuration are
904: DISEASES OF THE NERVOUS SYSTEM.
common. Localized bone-disease, suppuration in the liver, but, above
all, certain inflammations in the lungs (particularly gangrene, bronchi-
ectasis, and fetid bronchitis), are liable to be followed by abscess. It is
an occasional complication of empyema. Abscess of the brain may follow
tlie specific fevers. Bristowe has called attention to its occurrence as a
sequel of influenza. The largest number of cases occur between the twen-
tieth and fortieth years, and the condition is more frequent in men than
in women.
Morbid Anatomy. — The abscess may be solitary or multiple, dif-
fuse or circumscribed. In the acute, rapidly fatal cases following injury
the supj^uration is not limited ; but in long-standing cases the abscess is
enclosed in a definite capsule, which may have a thickness of from two to
five millimetres. The pus varies much in appearance, depending upon
the age of the abscess. In early cases it may be mixed with reddish
debris and softened brain matter, but in the solitary encapsulated abscess
the pus is distinctive, having a greenish tint, an acid reaction, and a pe-
culiar odor, sometimes like sulphuretted hydrogen. The brain substance
surrounding the abscess is usually oedematous and infiltrated. The size
varies from that of a walnut to that of a large orange. There are cases
on record in which the cavity has occupied the greater portion of a hemi-
sphere. Multiple abscesses are usually small. In four fifths of all cases
the abscess is solitary. Suppuration occurs most frequently in the cere-
brum, and the temporo-sphenoidal lobe is more often involved than other
parts. The cerebellum is the next most common seat, particularly in con-
nection with ear-disease.
Symptoms. — Following injury or operation the disease may run an
acute course, with fever, headache, delirium, vomiting, and rigors. The
symptoms are those of an acute meningo-encephalitis, and it may be very
difficult to determine, unless there are localizing symptoms, whether there is
really suppuration in the brain substance. In the cases following ear dis-
ease the symptoms may at first be those of meningeal irritation. There
may be irritability, restlessness, severe headache, and aggravated earache.
Other striking symptoms, particularly in the more prolonged cases, are
drowsiness, slow cerebration, vomiting, and optic neuritis. In the chronic
form of brain abscess which may follow injury, otorrhoea, or local lung
trouble, there may be a latent period ranging from one or two weeks to
several months, or even a year or more. In the " silent " regions, when
tlie abscess becomes encapsulated there may be no symptoms whatever
duriug the latent period. During all this time the patient may be under
careful observation and no suspicion be aroused of the existence of sup-
puration. Then severe headache, vomiting, fever, set in, joerhaps witli
a cliill. An Arab was admitted to my wards at the University Hos-
pital in a condition of profound anaemia, having been picked up by the
police in the street, covered with blood. There was a small localized area
of dulness in the third and fourth interspaces on the right side close to the
AFFECTIONS OF THE SUBSTANCE. 005
sternum, and although no tubercle bacilli were found, it was thought to
be probably a localized tuberculosis. He recovered rapidly from the anae-
mia, and within three months was strong and well. A few days before
his intended discharge he began to complain of headache, which became
aggravated. He had vomiting, fever, and gradually increasing coma. A
large, solitary encapsulated abscess was found in the parieto-occipital region
of the left hemisphere, and in the middle lobe of the right lung a circum-
scribed cavity, probably bronchiectatic, surrounded by fibroid tissue and
containing a very offensive pus. So, too, after a blow upon the head or a
fracture the symptoms of the lesion may be transient, and months after-
ward cerebral symptoms of the most aggravated character may develop.
The localization of the lesion is often difficult. In or near the motor
region there may be convulsions or paralysis, and it is to be remembered
that an abscess in the temporo-sphenoidal lobe may compress the lower
motor centres and produce paralysis of the arm and face and on the left side
cause aphasia. A large abscess may exist in the frontal lobe without caus-
ing paralysis, but in these cases there is almost always some mental dulness.
In the temporo-sphenoidal lobe, the common seat, there may be no focaliz-
ing symptoms. So also in the parieto-occipital region ; though here early
examination may lead to the detection of hemianopia. In abscess of the
cerebellum vomiting is common. If the middle lobe is affected there may
be staggering — cerebellar incoordination. Localizing symptoms in the
pons and other parts are still more uncertain.
Diagnosis. — In the acute cases there is rarely any doubt. The his-
tory of injury followed by fever, marked cerebral symptoms, the develop-
ment of optic neuritis and rigors, delirium, and perhaps paralysis, make
the diagnosis certain. In chronic ear-disease, such cerebral symptoms as
drowsiness and torpor, with irregular fever, supervening upon the cessation
of a discharge should excite the suspicion of abscess. It is particularly
in the chronic cases that difficulties arise. The symptoms resemble those
of tumor of the brain ; indeed, they are those of tumor plus fever. In a
patient with a history of trauma or with localized lung or pleural trouble,
who for weeks or months has had slight headache or dizziness, the onset of
a rapid fever, intense headache, and vomiting point strongly to abscess.
It is not always easy to determine whether the meninges are involved
with the abscess. Often in ear-disease the condition is that of meningo-
encephalitis. I have already referred to a condition sometimes associated
with ear-disease, which may simulate closely cerebral meningitis or even
abscess. Indeed, Gowers states that not only may these general symptoms
be produced by ear-disease, but even distinct optic neuritis.
Treatment. — A remarkable advance has been made of late years in
dealing with these cases, owing to the impunity with which the brain can
be explored. In ear-disease free discharge of the inflammatory products
should be promoted and careful disinfection practised. The treatment of
injuries and fractures comes within the scope of the surgeon. Tlie acute
906 DISEASES OF THE NERVOUS SYSTEM.
symptoms, such as fever, headache, and delirium, must be treated by rest,
an ice-cap, and, if necessary, local depletion. In all cases, when a reason-
able suspicion exists of the occurrence of abscess, the trephine should be
applied and the brain explored. The cases following ear-disease, in which
the suppuration is in the temporo-sphenoidal lobe or in the cerebellum,
offer the most favorable chances of recovery. The localization can rarely
be made accurately in these cases, and the operator must be guided more
by general anatomical and pathological knowledge. In cases of injury the
trephine should be applied over the seat of the blow or the fracture. In
ear-disease the suppuration is most frequent in the temporo-sphenoidal or
in the cerebellum, and the operation should be performed at the points
most accessible to these regions.
IV. HEMIPLEGIA AND DIPLEGIA IN CHILDREN.
It is as yet hard to say, without fuller knowledge of the etiology of
these common conditions, where they should be classified. In a majority
of the cases, whatever the nature of the primary pathological change, the
final state is one of a chronic encephalitis, often with great atrophy of the
convolutions or the formation of large cyst-like spaces — porencephalus.
I. Hemiplegia.
Etiology. — Of 135 cases, comprising those from the Infirmary for
Diseases of the Nervous System, Philadelphia, from the Elwyn Institution
for Feeble-minded Children, under Kerlin, and from my clinic at the Johns
Hopkins Hospital, 60 were in boys and 75 in girls. Eight hemiplegia
occurred in 79, left in 56. In 15 cases the condition was said to be con-
genital.
In a great majority the disease sets in during the first or second year ;
thus of the total number of cases, 95 were under two. Cases above the
fifth year are rare, only 10 in my series. Neither alcoholism nor syphilis
in the parents appears to play an important role in this affection. Diffi-
cult or abnormal labor is responsible for certain of the cases, particularly
injury with the forceps. Trauma, such as falls or puncturing wounds, is
more rare. The condition followed ligation of the common carotid in one
case.
Infectious diseases. All the authors lay special stress upon this factor.
In 19 cases in my series the disease came on during or just after one
of the specific fevers. I saw one case in which during the height of
vaccination convulsions developed, followed by hemiplegia. In a great
majority of the cases the disease sets in with a convulsion, in which the
child may remain for several hours or longer, and after recovery the paraly-
sis is noticed.
HEMIPLEGIA AND DIPLEGIA IN CHILDREN. 907
Morbid Anatomy. — In an analysis which I have made of 90 au-
topsies reported in the literature, the lesions may be grouped under three
headings :
(a) Embolism, thrombosis, and haemorrhage, comprising IG cases,
in 7 of which there was blocking of a Sylvian artery, and in 9 haemor-
rhage. A striking feature in this group is the advanced age of onset.
Ten of the cases occurred in children over six years old.
(b) Atrophy and sclerosis, comprising 50 cases. The wasting is either
of groups of convolutions, an entire lobe, or the whole hemisphere. The
meninges are usually closely adherent over the affected region, though
sometimes they look normal. The convolutions are atrophied, firm, and
hard, contrasting strongly with the normal gyri. The sclerosis may be
diffuse and wide-spread over a hemisphere, or there may be nodular pro-
jections— the hypertrophic sclerosis. Some of the cases show remarkable
unilateral atrophy of the hemisphere. In one of my cases the atrophied
hemisphere weighed 169 grammes and the normal 653 grammes. The
brain tissue may be a mere shell over a dilated ventricle.
(c) Porencephalus, which was present in 24 of the 90 autopsies. This
term was applied by Heschel to a loss of substance in the form of cavi-
ties and cysts at the surface of the brain, either opening into and bounded
by the arachnoid, and even passing deeply into the hemisphere, or reach-
ing to the ventricle. In the study by Audrey of 103 cases of porencepha-
lus, hemiplegia was mentioned in 68 cases.
Practically, then, in infantile hemiplegia cortical sclerosis and poren-
cephalus are the important anatomical conditions. The primary change
in the majority of these cases is still unknown. Porencephalia may result
from a defect in development or from haemorrhage at birth. The etiology
is clear in the limited number of cases of haemorrhage, embolism, and
thrombosis, but there remains the large group in which the final change
is sclerosis and atrophy. What is the primary lesion in these instances ?
The clinical history shows that in nearly all these cases the onset is sud-
den, with convulsions — often with slight fever. Striimpell believes that
this condition is due to an inflammation of the gray matter — polio-en-
cephalitis— a view which has not been very widely accepted, as the ana-
tomical proofs are wanting. Gowers suggests that thrombosis may be
present in some instances. This might probably account for the final
condition of sclerosis, but clinically thrombosis of the veins rarely occurs
in healthy children, which appear to be those most frequently attacked
by infantile hemiplegia, and post-mortem proof is yet wanting of the
association of thrombosis with the disease.
Symptoms. — (a) The onset. The disease may set in suddenly
without spasms or loss of consciousness. In more than half the cases the
child is attacked with partial or general convulsions and loss of conscious-
ness, which may last from a few hours to many days. This is one of the
most striking features in the disease. Fever is usually present. The
908 DISEASES OF THE NERVOUS SYSTEM.
hemiplegica, noticed as the child recovers consciousness, is generally com-
plete. Sometimes the paralysis is not complete at first, but develops after
subsequent convulsions. The right side is more frequently affected than
the left. The face is commonly not involved.
(b) Eesidual symptoms. In some cases the paralysis gradually disap-
pears and leaves scarcely a trace as the child grows up. The leg, as a
rule, recovers more rapidly and more fully than the arm, and the
paralysis may be scarcely noticeable. In a majority of cases, however,
there is a characteristic hemiplegic gait. The paralysis is most marked
in the arm, which is usually wasted ; the forearm is flexed at right angles,
the hand is flexed, and the fingers are contracted. Motion may be almost
completely lost ; in other instances the arm can be lifted above the head.
Late rigidity, which almost always develops, is the symptom which
suggested the name Jiemiplegia spastica cerehrahs to Heine, the ortho-
paedic surgeon who first accurately described these cases. It is, however,
not constant. The limbs may be quite relaxed even years after the onset.
The reflexes are usually increased. In several instances, however, I have
known them to be absent. Sensation is, as a rule, not disturbed.
Aphasia is a not uncommon symptom, and occurred in 16 cases of my
series — a smaller number than given in the series of Wallenberg, Gaudard,
and Sachs.
Mental Defects. — One of the most serious consequences of infantile
hemiplegia is the failure of mental development. A considerable number
of these cases drift into the institutions for feeble-minded children. Three
grades may be distinguished — idiocy, which is most common when the
hemiplegia has existed from birth ; imbecility, which often increases with
the development of epilepsy; and feeble-mindedness, a retarded rather
than an arrested development.
Epilepsy. — Of the cases in my series, 41 were subjects of convulsive
seizures, which is one of the most distressing sequences of the disease.
The seizures may be either transient attacks of j)etit mal, true Jacksonian
fits, beginning in and confined to the affected side, or general convulsions.
Post -hemiplegic Movemerits. — It was in cases of this sort that Weir
Mitchell first described the post-hemiplegic movements. They are ex-
tremely common, and were present in 34 of my series. There may be
either slight tremor in the affected muscles, or incoordinate choreiform
movements — the so-called post-hemiplegic chorea — or, lastly.
Athetosis. — In this condition, described by Hammond, there are re-
markable spasms of the paralyzed extremities, chiefly of the fingers and
toes, and in rare instances of the muscles of the mouth. The movements
are involuntary and somewhat rhythmical ; in the hand, movements of
adduction or abduction and of supination and pronation follow each
other in orderly sequence. There may be hyperextension of the fingers,
during which tlioy are spread wide apart. This condition is much more
frequent in children than in adults. In the latter it may be combined
HEMIPLEGIA AND DIPLEGIA IN CHILDREN. QOy
witli liemianoestliesia, and tlio le.sioii is not cortical, but basic in the noi<^h-
borhood of the thahimus. The movements are sometimes increased by
emotion. They usually persist during sleep.
II. Spastic Diplegia — Birth Palsies.
In this condition there is a paralysis with spasm of all extremities,
dating from or shortly succeeding birth, more rarely following the fevers
or an attack of convulsions. The legs are usually more involved than the
arms ; there is no wasting, no disturbance of sensation. The reflexes are
increased. The mental condition is profoundly disturbed. The patients
are usually imbeciles or idiots, helpless in mind and body. Ataxic and
athetoid movements of the most exaggerated kind may occur.
While a limited number only of cases of infantile hemiplegia are
congenital, on the other hand, in spastic diplegia a large proportion of
the cases results from injury at birth. Practically the spastic paraplegia of
children should be considered with this condition, as its etiology is essen-
tially the same. The arms, too, may be so slightly affected as to make it
difficult to determine whether it is a case of diplegia or paraplegia. The
cases usually date from birth, and a majority are born in first labors or
are forceps cases. Eoss suggests that in feet presentation there may be
laceration or tearing of the cerebro-spinal membranes.
Morbid Anatomy. — The birth palsies which ultimately induce the
spastic diplegias or paraplegias are most frequently the result of meningeal
haemorrhage. The importance of this condition has been shown by the
studies of Litzmann and Sarah J. Mcl^utt. The bleeding may come
from the veins, or, in one case which I saw with Hirst, from the longi-
tudinal sinus. The bleeding has in many cases been thickest over the
motor areas, and it seems probable that the sclerosis found in these cases
may result from the compression of the blood-clot. In other instances
the condition may be due to a foetal meningo-encephalitis. In sixteen
autopsies collected in the literature, in which the patients died at ages
varying from two to thirty, the anatomical condition was either a diffuse
atrophy, which was most common, or porencephalus.
Symptoms. — At first nothing abnormal may be noticed about the
child. In some instances there have been early and frequent convul-
sions ; then at the age when the child should begin to walk it is noticed
that the limbs are not used readily, and on examination a stiffness of the
legs and arms is found. Even at the age of two the child may not be
able to sit up, and often the head is not well supported by the neck mus-
cles. The rigidity, as a rule, is more marked in the legs, and there is ad-
ductor spasm. When supported on the feet, the child either rests on its
toes and the inner surface of the feet, with the knees close together, or the
legs may be crossed. The stiffness of the upper limbs varies. It may be
scarcely noticeable or the rigidity may be as marked as in the legs. Con-
910 DISEASES OF THE NERVOUS SYSTEM.
stant irregular movements of the arms are not uncommon. The child
has great difficulty in grasping an object. The spasm and weakness may be
more evident on one side than the other. The mental condition is, as a
rule, defective and convulsive seizures are common.
Associated with the spastic paraplegia are two allied conditions of con-
siderable interest, characterized by spasm and disordered movements. A
child with spastic diplegia may present, in an unusual degree, irregular
movements of the muscles. In attempting to grasp an object the fingers
may be thrown out in a stiff, spasmodic, irregular manner, or there may be
constant irregular movements of the shoulders, arms, and hands, with
slight incoordination of the head. Cases of this description have been de-
scribed as chorea spastica^ and they may be difficult to separate from mul-
tiple sclerosis and from Friedreich's ataxia.
A still more remarkable condition is that of lilateral athetosis, in
which there is a combination of spasm more or less marked with the most
extraordinary bizarre movements of the muscles. The condition, as a
rule, dates from infancy. The patient may not be able to walk. The head
is turned from side to side ; there are continual irregular movements of
the face muscles, and the mouth is drawn and greatly distorted. The
extremities are more or less rigid, particularly in extension. On making
the slightest attempt to move, often spontaneously, there are extraordinary
movements of the arms and legs, particularly of the arms, somewhat like
though much more exaggerated than athetosis. The patients are often
unable to help themselves on account of these movements. The reflexes
are increased. The mental condition is variable. The patient may be
idiotic, but in two of the four cases which I have seen the patients were
intelligent. Massalongo,* who has carefully studied this condition, describes
three cases in one family. I have collected fifty-three cases from the
literature, thirty-three of which occurred in males and twenty in females.
There have been three autopsies. In Kurella's case there was pachy-
meningitis and bilateral lesions of the motor convolutions. Dejerine's pa-
tient had atrophy of the convolutions on both sides, while in my case the
brain macroscopically presented no changes.
III. Spastic Paraplegia.
This condition, which is more fully described under the section upon
the spinal cord, is in reality a cerebral affection, and may be due to condi-
tions similar to those found in spastic diplegia. Indeed, it may at first be
difficult to determine whether the arms are involved or not. The evi-
dence of the cerebral origin of the affection is based upon the frequent co-
existence of idiocy, imbecility, and nystagmus, and the occurrence of cases of
spastic diplegia, in which the paraplegic symptoms are identical. All
grades are met with, from pure spastic paraplegia with perfect use of the
* Deir Atetosi Doppia, Collezione Italiana di Letture sulla Medicina, Series V, N. 3.
SCLEROSIS OF THE BRAIN. 9J1
arms to the most extreme bilateral spasm. There have been, so far as I
know, only two autopsies in this disease : the case of Forster, in which
there was a moderate grade of general cortical sclerosis with slight dilata-
tion of the ventricles, and the recent case of Sachs, in which there was a
meningo-encephalitis with atrophy and descending degeneration of both
lateral columns.
Treatment. — The possibility of injury to the brain in protracted
labor and in forceps cases should be borne in mind by the practitioner.
The former entails the greatest risk. In infantile hemiplegia the physi-
cian at the outset sees a case of ordinary convulsions, perhaps more pro-
tracted and severe than usual. These should be checked as rapidly as
possible by the use of the bromides, the application of cold or heat, and a
Tarisk purge. During convulsions chloroform may be administered with
safety even to the youngest children. AYhen the paralysis is established
not much can be hoped from medicines. In only rare instances does the
paralysis entirely disappear. The indications are to favor the natural
tendency to improve by maintaining the general nutrition of the child, to
lessen the rigidity and contractures by massage and passive motion, and
if necessary to correct deformities by mechanical or surgical measures.
Much may be done by careful manipulation and rubbing and the applica-
tion of a proper apparatus. In children the aphasia usually disappears.
The epilepsy is a distressing and obstinate symptom, for which a cure
can rarely be anticipated. Prolonged periods of quiescence are, however,
not uncommon. In the Jacksonian fits the bromides rarely do good, un-
less there is much irritability and excitement. Operative measures,
which have been carried out in several cases, have not been successful.
The liability to feeble-mindedness is the most serious outlook in the in-
fantile cerebral palsies. In many cases the damage is irreparable, and
idiocy and imbecility result. With patient training and with care many
of the children reach a fair measure of intelligence and self-reliance.
V. SCLEROSIS OF THE BRAIN.
General Kemarks. — The connective tissue of the central nervous
system is of two kinds — one, the neuroglia, special and peculiar, derived
from the ectoderm, with distinct morphological and chemical characters ;
the other, derived from the m.esoderm, identical with the ordinary col-
lagenous fibrous tissue of the body. Both play important parts in indura-
tive processes in the brain and cord. A convenient division of the cerebro-
spinal scleroses is into degenerative, inflammatory, and developmental
forms.
The degenerative scleroses comprise the largest and most important
subdivision, in which provisionally the following groups may be made:
{a) The common secondary degeneration which follows when nerve-fibres
912 DISEASES OF THE NERVOUS SYSTEM.
are cut oiT from their trophic centres ; (b) toxic forms, among which may
be placed the scleroses from lead and ergot, and, most important of all, the
sclerosis of the posterior column, due in such a large proportion of cases to
the virus of syphilis. Other unknown toxic agents may j^ossibly induce
degeneration of the nerve-fibres in certain tracts. The systemic paths in
the cord differ apparently in their susceptibility and the posterior columns
appear most prone to undergo this change ; (c) the sclerosis associated
with change in the smaller arteries and capillaries, which is met with as a
senile process in the convolutions. In all probability some of the forms of
insular sclerosis are due to primary alterations in the blood-vessels ; but
it is not yet settled whether the lesion in these cases is a primary degen-
eration of the nerve cells and fibres to which the sclerosis is secondary, or
whether the essential factor is an alteration in nutrition caused by lesions
of the capillaries and smaller arteries.
The injlammat07'y scleroses embrace a less important and less extensive
group, comprising secondary forms which develop in consequence of irri-
tative inflammation about tumors, foreign bodies, haemorrhages, and abscess.
Histologically these are chiefly mesodermic (vascular) scleroses, which arise
from the connective tissue about the blood-vessels. Possibly a similar
change may follow the primary, acute encephalitis, which Striimpell holds
is the initial lesion in the cortical sclerosis which is so commonly found
post mortem in infantile hemiplegia. *
The developmental scleroses are believed to be of a purely neurogliar
character, and embrace the new growth about the central canal in
syringomyelia and, according to recent French writers, the sclerosis of
the posterior columns in Friedreich's ataxia. It is stated that histo-
logically this form is different from the ordinary variety. It may be,
too, that the diffuse cortical sclerosis met with as a congenital condi-
tion without thickening of the meninges belongs to this type. It is
not improbable that many forms of sclerosis are of a mixed character,
in which both the ectodermic and mesodermic connective tissues are in-
volved.
Anatomically we meet with the following varieties :
(1) Miliary sclerosis is a term which has been applied to several dif-
ferent conditions. Gowers mentions a case in which there were grayish-
red spots at the junction of the white and gray matters, and in which the
neuroglia was increased. There is also a condition in which, on the sur-
face of the convolutions, there are small nodular projections, varying from
a lialf to five or more millimetres in diameter. Single nodules of this s©rt
are not uncommon ; sometimes they are abundant. So far as is known no
symptoms are produced by them.
(2) Diffuse sclerosis, which may involve an entire hemisphere, or a
single lobe, in which case the term sclerose lohaire has been applied to it
by the French. It is not an important condition in general medical
practice, but occurs most frequently in idiots and imbeciles. In extensive
SCLEROSIS OF THE BRAIN. 913
cortical sclerosis of one hemisphere the ventricle is usually dilated.* The
symptoms of this condition depend upon the region aifected. There may
be a considerable extent of sclerosis without symptoms or without much
mental impairment. In a majority of cases there is hemiplegia or diplegia
with imbecility or idiocy.
(3) Tuberous Sclerosis. — In this remarkable form, which is also known
as hypertrophic, there are on the convolutions areas projecting beyond
the surface of an opaque white color and exceedingly firm. The sclerosis
may not disturb the symmetry of the convolution, but simply cause a great
enlargement, increase in the density, and a change in the color.
These three forms are not of much practical interest except in asylum
and institution work. The last variety forms a well-characterized disease
of considerable importance, namely :
(4) Insular Sclerosis {Sclerose en plaques).
Definition. — A chronic affection of the brain and cord, characterized
by localized areas in which the nerve elements are more or less replaced by
connective tissue. This may occur in the brain or cord alone, more
commonly in both.
Etiology. — This is obscure. Kahler, Marie, and others assign great
importance to the infectious diseases, particularly scarlet fever. It is
found most commonly in middle-aged persons, but cases are not uncom-
mon in children, in whom Pritchard states that more than fifty cases have
been reported, f
Morbid Anatomy. — The sclerotic areas are widely distributed
through the brain and cord. Cases limited to the cord are almost un-
known. On section of the brain, grayish-red areas are seen scattered
through the white matter. The cortex is not often involved. The patches
are sometimes abundant in the neighborhood of the ventricles, and in the
pons, cerebellum, basal ganglia, and the medulla. The cord may be only
slightly involved or there may be irregular areas in different regions.
Histologically in the sclerosed patches there is great increase in the con-
nective tissue, the fibres of which are denser and firmer. The gradual
growth destroys the medulla of the nerves, but the axis cylinders persist
in a remarkable way.
Symptoms. — The onset is slow and the disease is chronic. Feeble-
ness of the legs with irregular pains and stiffness are among the early
symptoms. Indeed, the clinical picture may be that of spastic paraplegia
with great increase in the reflexes. The following are the most important
features :
(a) Volitional Tremor. — There is no paralysis of the arms, but on at-
* In my monograph on Cerebral Palsies of Children I have given a description of
the distribution of the sclerosis in ten specimens in the museum at the Elwyn Institution,
f Cyclopedia of the Diseases of Children, vol. iv.
914: DISEASES OF THE NERVOUS SYSTEM.
tempting to pick up an object there is trembling or rapid oscillation. A
patient may be unable to lift even a glass of water to the mouth. The
tremor may be marked in the legs and in the head, which shakes as
he walks. When the patient is recumbent the muscles may be per-
fectly quiet. On attempting to raise the head from the pillow, trembling at
once comes on. (b) Scanning Speech. — The words are pronounced slowly
and separately, or the individual syllables may be accentuated. This
staccato or syllabic utterance is a common feature, {c) Nystagmus, a
raj^id oscillatory movement of both eyes, constitutes an important symptom.
Sensation is unaffected in a majority of the cases. Optic atrophy some-
times occurs, but not so frequently as in tabes. The sphincters, as a rule,
are unaffected until the last stages. Mental debility is not uncommon.
Remarkiible remissions occur in the course of the disease, in which for a
time all the symptoms may improve. Vertigo is common, and there may
be sudden attacks of coma, such as occur in general paresis.
The diagnosis in well-marked cases is easy. Additional tremor, scan-
ning speech, and nystagmus form a characteristic symptom-group. With
this there is usually more or less spastic weakness of the legs. Paralysis
agitans, certain cases of general paresis, and occasionally hysteria may
simulate the disease very closely. If the case is not seen until near the
end the diagnosis may be impossible. Buzzard holds that of all organic
diseases of the nervous system disseminated sclerosis in its early stages is
that which is most commonly mistaken for hysteria.
Much more puzzling, however, are the instances of pseudo-scUrose en
plaques^ which have been described by Westphal. The volitional tremor,
the scanning speech, and the spastic condition are present, but no lesions
have been found post mortem. The movements in this form are more
violent, but nystagmus does not occur. Some of the cases may possibly be
examples of general paresis. In children the condition may with difficulty
be separated from Friedreich's ataxia.
The prognosis is unfavorable. Ultimately, the patient, if not carried
off by some intercurrent affection, becomes bedridden.
Treatment. — No known treatment has any influence on the prog-
ress of sclerosis of the brain. Neither the iodides nor mercury have the
slightest effect, but a prolonged course of nitrate of silver may be tried.
VI. CHRONIC DIFFUSE MENINGO-ENCEPHALITIS
{Dementia Paralytica ; General Paresis).
Definition. — A chronic, progressive meningo-encephalitis associated
with psychical and motor disturbances, finally leading to dementia and
paralysis.
Etiology. — Males are affected much more frequently than females.
It occurs chiefly between the ages of thirty and fifty-five. Heredity is a
CJIRONIC DIFFUSE iMP]NINGO-ENCEPlI A LITIS. 915
factor in only a few cases. An ovorwhelniing majority of the cases are in
married people. Statistics show that it is more common in the lower classes
of society, but in this country in general medical practice the disease is
certainly more common in the well-to-do classes. An important i)redis-
posing cause is " a life absorbed in ambitious projects with all its strongest
mental efforts, its long-sustained anxieties, deferred hopes, and straining
expectation " (Mickle). The habits of life so frequently seen in active
business men in our large cities, and well expressed by the phrase " burn-
ing the candle at both ends," strongly predispose to the disease. Among
other factors of importance are syphilis, excesses in haccho et venere, in-
juries, and chronic lead-poisoning.
Morbid Anatomy. — The essential histological changes in the cere-
bral cortex are thus summarized by Bevan Lewis : (1) A stage of inflam-
matory change in the tunica adventitia of the arteries with excessive nu-
clear proliferation, profound changes in the vascular channels, and trophic
changes induced in the tissues around.
(2) A stage of extraordinary development of the lymph-connective
system of the brain, with a parallel degeneration and disappearance of
nerve elements and the axis cylinders of which they are denuded.
(3) A stage of general fibrillation with shrinking and extreme atrophy
of the parts involved.
The macroscopical changes are : {a) Increase in the cerebro-spinal
fluid, oedema of the pia, and thickening and opacity of the meninges, which
are adherent in places and tear the cortex on removal. The dura is some-
times thickened, and pachymeningitis haemorrhagica interna may be
present.
(b) The convolutions are atrophied, usually in a marked degree, and
in consequence the brain looks small. This is particularly noticeable in
the frontal and parietal regions. On section it cuts with firmness. In
extreme cases the gray matter may be obscurely outlined. The grade of
sclerosis varies much in different cases. The white matter may be firmer
in consistence, but it does not show such important changes. The ven-
tricles are dilated and the ependyma extremely granular. In addition,
there are frequently areas of softening or haemorrhage associated with
chronic arterio-sclerosis.
(c) Spinal cord. Changes occur leading to increase in the connective-
tissue elements and frequently to degeneration of the pyramidal tracts
secondary to the cortical lesion. The posterior columns may also be in-
volved, and occasionally the distribution of the sclerosis is that of the
amyotrophic form.
Symptoms. — {a) Prodromal Stage. — I'his is of variable duration,
and is cliaracterized by a general mental state which finds expression in
symptoms trivial in themselves but important in connection with others.
Irritability, inattention to business amounting sometimes to indifference
or apathy, and sometimes a change in character marked by acts which
58
916 DISEASES OP THE NERVOUS SYSTEM.
may astonish the friends and relatives may be the first indications. In-
stead of apathy or indiiference there may be an extraordinary degree of
physical and mental restlessness. The patient is continually planning and
scheming, or may launch into extravagances and speculation of the wildest
character. A common feature at this period is the display of an un-
bounded egoism. He boasts of his personal attainments, his property, his
position in life, or of his wife and children. Following these features are
important indications of moral perversion, manifested in offences against
decency or the law, many of which acts have about them a suspicious
effrontery. Forgetfulness is common, and may be shown in inattention to
business details and in the minor courtesies of life. At this period there
may be no motor phenomena. The onset of the disease is usually insidi-
ous, although cases are reported in which epileptiform or apoplectiform
seizures were the first symptoms. Among the early motor features are
tremor of the tongue and lips in speaking, slowness of speech and hesi-
tancy, and inequality of the pupils.
(b) Second Stage. — This is characterized in brief by mental exaltation
or excitement and a progress in the motor symptoms. " The intensity of
the excitement is often extreme, acute maniacal states are frequent ; in-
cessant restlessness, obstinate sleeplessness, noisy, boisterous excitement,
and blind, uncalculating violence especially characterize such states "
(Lewis). It is at this stage that the delusion of grandeur becomes marked
and the patient believes himself to be possessed of countless millions or to
have reached the most exalted sphere possible in profession or occupation.
This expansive delirium, as it is called, is, however, not characteristic, as
was formerly supposed, of paralytic dementia. Besides, it does not always
occur, but in its stead there may be marked melancholia or hypochon-
driasis, or, in other instances, alternate attacks of delirium and depres-
sion.
The facies has a peculiar stolidity, and in speaking there is marked
tremulousness of the lips and facial muscles. The tongue is also tremu-
lous, and may be protruded with difficulty. The speech is slow, inter-
rupted, and blurred. Writing becomes difficult on account of unsteadi-
ness of the hand. The subject matter of the patient's letters give valu-
able indications of the mental condition. In many instances the pupils
are unequal, irregular, sluggish, sometimes large. Important symptoms
in this stage are apoplectiform seizures and paralysis. There may be
slight syncopal attacks in which tlie patient turns pale and may fall.
Some of these are petit mal. In the true apoplectiform seizure tlie pa-
tient falls suddenly, becomes unconscious, the limbs are relaxed, the face
is flushed, the breathing stertorous, the temperature increased, and death
may occur. The epileptic seizures are more common than the apoplecti-
form and may occur early in the disease. A definite aura is not uncom-
mon. The attack usually begins on one side and may not spread. There
may be twitchings either in the facial or brachial muscles. Typical Jack-
CHRONIC DIFFUSE MENINGO-ENCEPIIALITIS. 917
sonian epilepsy may occur. In a case whicli died recently under my care,
these seizures were among the early symptoms and the disease was re-
garded as cerebral syphilis. Paralysis, either monoplegic or hemiplegic,
may follow these epileptic seizures, or may come on with great suddenness
and be transient. In this stage the gait becomes impaired, the patient
trips readily, has difficulty in going up or down stairs, and the walk may
be spastic or occasionally tabetic. This paresis may be progressive. The
knee-jerk is usually increased. Bladder or rectal symptoms gradually
develop. The patient becomes helpless, bedridden, and completely de-
mented, and unless care is taken may suffer from bedsores. Death occurs
from exhaustion or from some intercurrent affection.
Diagnosis. — The recognition of the disease in the earliest stage is ex-
tremely difficult, as it is often impossible to decide that the slight altera-
tion in conduct is anything more than one of the moods or phases to
which most men are at times subject. The following description by Fol-
som is an admirable presentation of the diagnostic characters of the early
stage of the disease : " It should arouse suspicion if, for instance, a strong,
healthy man, in or near the prime of life, distinctly not of the ' nervous,'
neurotic, or neurasthenic type, shows some loss of interest in his affairs or
impaired faculty of attending to them ; if he becomes varyingly absent-
minded, heedless, indifferent, negligent, apathetic, inconsiderate, and, al-
though able to follow his routine duties, his ability to take up new work
is, no matter how little, diminished ; if he can less well command mental
attention and concentration, conception, perception, reflection, judgment ;
if there is an unwonted lack of initiative, and if exertion causes unwonted
mental and physical fatigue ; if the emotions are intensified and easily
change, or are excited readily from trifling causes ; if the sexual instinct
is not reasonably controlled ; if the finer feelings are even slightly blunted ; if
the person in question regards with a placid apathy his own acts of indiffer-
ence and irritability and their consequences, and especially if at times he
sees himself in his true light and suddenly fails again to do so ; if any
symptoms of cerebral vaso-motor disturbances are noticed, however vague
or variable."
There are cases of cerebral syphilis whicli closely simulate dementia para-
lytica. The mode of onset is important, particularly since paralytic symp-
toms are usually early in syphilis. The affection of the speech and tongue
is not present. Epileptic seizures are more common and more liable to
be cortical or Jacksonian in character. The expansive delirium is rare.
While symptoms of general paresis are not common in connection with
the development of gummata or definite gummatous meningitis, there are,
on the other hand, instances of paresis which follow syphilitic infection
so closely that an etiological connection between the two must be acknowl-
edged. Post mortem in such cases there may be nothing more than a
general arterio-sclerosis and diffuse meningo-encephalitis, which may pre-
sent nothing distinctive, but the lesions, nevertheless, may be caused by
918 DISEASES OF THE NERVOUS SYSTEM.
the syphilitic virus. There are certain forms of lead encephalopathy which
resemble general paresis, and, considering the association of plumbism with
arterio-sclerosis, it is not unlikely that the anatomical substratum of the
disease may result from this poison.
Prognosis. — The disease rarely ends in recovery. As a rule the prog-
ress is slowly downward and the case terminates in a few years, although
it is occasionally prolonged ten or fifteen years.
Treatment. — The only hope of permanent relief is in the cases follow-
ing syphilis, which should be placed upon large doses of iodide of potas-
sium. Careful nursing and the orderly life of an asylum are the only
measures necessary in a great majority of the cases. For sleeplessness and
the epileptic seizures bromides may be used. Prolonged remissions, which
are not uncommon, are often erroneously attributed to the action of
remedies.
VII. TUMORS OF THE BRAIN.
The following are the most common varieties of new growths within
the cranium :
(a) Tubercle, which may form small or large growths, usually multiple.
They are most frequent early in life. Three fourths of the cases occur
under twenty, and one half of the patients are under ten years of age
(Gowers). Of 299 cases of tumor in persons under nineteen collected
from various sources by Starr, 152 were tubercle. They are most numer-
ous in the cerebellum and about the base.
[h) Srjphiloma is most commonly found in the hemispheres or about
the pons. The tumors are superficial, attached to the arteries or the me-
ninges, and rarely grow to a large size. They may be multiple.
(c) Glioma and Neuroglioma. — These vary greatly in appearance. They
may be firm and hard, almost like an area of sclerosis, or soft and very
vascular. They persist remarkably for many years. Klebs has called
attention to the occurrence of elements in them not unlike ganglion-cells.
Tumors of this character contain " the spinnen " or spider cells ; enormous
spindle-shaped cells with single large nuclei ; cells like the ganglion-cells
of nerve-centres with nuclei and one or more processes ; and translucent,
band-like fibres, tapering at each end, which result from a vitreous or hya-
line transformation of the large spindle-cells.
(d) Sarcoma occurs most commonly in the membranes of the brain
and in the pons. It forms some of the largest and most diffusely infil-
trating of intracranial growths.
(e) Carcinoma not infrequently is secondary to cancer in other parts.
It is seldom primary. Occasionally cancerous tumors have been found in
symmetrical parts of the brain.
(/) Other varieties occur, such as fibroid growths, which usually
develop from the membranes ; bony tumors, which grow sometimes from
TUMORS OF THE BllAlN. 919
the falx, and psammoma and cholesteatoma. Fatty tumors are occasion,
ally found on the corpus callosum.
iff) Cysts occur between the membranes and the brain, the result of
haemorrhage or of softening. Porencephalus is a sequence of congenital
atrophy or of haemorrhage, or may be due to a developmental defect.
Hydatid cysts will be referred to in the section on parasites.
Symptoms.— (1) General. — The following are the most important:
Headache^ either dull, aching, and continuous, or sharp, stabbing, and par-
oxysmal. It may be diffused over the entire head or limited to the back
or front. In the former case it may extend down the neck, and in the
latter be accompanied with neuralgic pains in the face. Occasionally the
pain may be very localized and associated with tenderness on pressure.
Optic Neuritis. — This occurs in four fifths of all the cases (Gowers).
It is usually double, but occasionally is found in only one eye. A growth
may develop slowly and attain considerable size without producing optic
neuritis. On the other hand, it may occur with a very small tumor, more
commonly in a growth at the base.
Vomiting. — This is a common feature, and with headache and optic
neuritis makes up the characteristic symptom group of cerebral tumor.
An important point is the absence of definite relation to the meals. It
may be very obstinate, particularly in growths of the cerebellum and the
pons.
Giddiness. — This is often an early symptom. The patient complains
of vertigo on rising suddenly or on turning quickly. Mental Disturhance.
The patient may act in an odd, unnatural manner, or there may be stupor
and heaviness. The patient may become emotional or silly, or symptoms
resembling hysteria may develop. Coiivulsions, either general and resem-
bling true epilepsy or localized (Jacksonian) in character.
(2) Localizing Symptoms. — (a) Central Motor Area.— The symptoms
are either irritative or destructive in character. Irritation in the lower
third may produce spasm in the muscles of the face, in the angle of the
mouth, or in the tongue. The spasm with tingling may be strictly lim-
ited to one muscle group before extending to others, and this Seguin
terms the signal symptom. The middle third of the motor area contains
the centres controlling the arm, and here, too, the spasm may begin in
the fingers, in the thumb, in the muscles of the wrist, or in the shoulder.
In the upper third of the motor areas the irritation may produce spasm
beginning in the toes, in the ankles, or in the muscles of the leg. In
many instances the patient can determine accurately the point of origin
of the spasm, and there are important sensory disturbances, such as numb-
ness and tingling, which may be felt first at the region affected.
In all cases it is important to determine, first, the point of origin, the
signal symptom; second, the order or march of tlie spasm; and third,
the 8ubs(;quent condition of the jmrts first affected, whether it is a state of
paresis or anaisthesia.
920 DISEASES OF THE NERVOUS SYSTEM.
Destructive lesions in the motor zone cause paralysis, which is often
preceded by local convulsive seizures ; there may be a monoplegia, as of
the leg, and convulsive seizures in the arm, often due to irritation in
these centres. Tumors in the neighborhood of the motor area may cause
localized spasms and subsequently, as the centres are invaded by the
growth, paralysis occurs. On the left side, growths in the third frontal
or Broca's convolution may cause motor aphasia.
(b) Prefrontal Region. — Neither motor nor sensory disturbance may
be present. The general symptoms are often well marked. The most
striking feature of growths in this region is mental torpor and gradual
imbecility. In its extension downward the tumor may involve on the left
side the lower frontal convolution and produce aphasia, or in its progress
backward cause irritative or destructive lesions of the motor area.
(c) Tumors in the parieto-occipital lobe may grow to large size without
causing any symptoms. There may be word-blindness and mind-blindness
when the angular gyrus is involved, and paraphasia.
(d) Tumors of the occipital lobe produce hemianopia, and a bilateral
lesion may produce blindness. Tumors in this region on the left hemi-
sphere may be associated with word-blindness and mind-blindness.
(e) Tumors in the temporal lobe may attain a large size without pro-
ducing symptoms. In their growth they involve the lower motor centres.
On the left side involvement of the first and second gyri maybe associated
with word-deafness.
(/) Tumors growing in the neighborhood of the basal ganglia produce
hemiplegia from involvement of the internal capsule. Limited growths in
either nucleus of the corpus striatum do not necessarily cause paralysis.
Tumors in the thalamus opticus may also, when small, cause no symptoms,
but increasing they may involve the fibres of the optic radiation, produc-
ing hemianopia and sometimes hemiansesthesia. Growths in this situation
are apt to causo early optic neuritis and, growing into the third ventricle,
may cause a distention of the lateral ventricles. In fact, pressure symp-
toms from this cause and paralysis due to involvement of the internal
capsule are the chief symptoms of tumor in and about these ganglia.
Growths in the corpora qnadrigemina are rarely limited, but most com-
monly involve the crura cerebri as well. Ocular symptoms are marked.
The pupil reflex is lost and there is nystagmus. In the gradual growth
the third nerve is involved as it passes through the crus, in which case there
will be motor oculi paralysis on one side and hemiplegia on the other, a
combination almost characteristic of unilateral crus disease.
(//) Tumors of i\\G pons and medulla. The symptoms are chiefly those
of pressure upon the nerves emerging in this region. In disease of the
pons the nerves may be involved alone or with the tract. Of 52 cases
analyzed by Mary Putnam Jacobi, there were 13 in which the cranial
nerves were involved alone, 13 in which the limbs were affected, and 26 in
which there was hemiplegia and involvement of the nerves. Twenty-two
TUMORS OF THE BRAIN. 921
of the latter had what is known as alternate paralysis — i. c, involvement
of the nerves on one side and the limbs on the opposite side. In four
cases there were no motor symptoms. A tumor growing in the lower part
of the pons usually involves the sixth nerve, producing internal strabis-
mus ; the seventh nerve, producing facial paralysis ; and the auditory nerve,
causing deafness. Conjugate deviation of the eyes to the side opposite
that on which there is facial paralysis also occurs.
Tumors of the medulla may involve the cranial nerves alone or cause
in some instances a combination of hemiplegia with paralysis of the nerves.
Signs of irritation in the ninth, tenth, and eleventh nerves are usually
present, and produce difficulty in swallowing, irregular action of the heart,
irregular respiration, vomiting, and sometimes retraction of the head and
neck. The gait may be unsteady or, if there is pressure on the cerebellum,
ataxic. Occasionally there are sensory symptoms, numbness, and tingling.
Toward the end convulsions may occur.
(h) Tumors of the cerelelliim constitute by far the most important
affection of this part. There may be no symptoms whatever if the tumor
is confined to one hemisphere and does not involve the middle lobe. When
this portion is affected the symptoms are very characteristic, consisting of :
Vertigo^ which is more constant in this than in affections of any other
region of the brain. This may be due, some believe, to the central rela-
tions of the semicircular canals with the cerebellum. The giddiness may
be of the most distressing nature.
Headache. — In the analysis by Mary Putnam Jacobi of symptoms in
tumors in various parts of the brain headache was relatively much more
frequent in tumors of the cerebellum than in any other region.
Cerebellar Ataxia. — The gait is irregular and staggering. In attempt-
ing to walk the patient reels to and fro like a drunken man. There may
be a tendency to fall to one side, backward, or, less commonly, forward.
Other less constant but suggestive symptoms are the optic neuritis ;
nystagmus ; neuralgic pains in the region of the neck and occiput ; press-
ure symptoms on the medulla, causing vomiting ; distention of the lateral
ventricles, causing in children hydrocephalus ; and, lastly, bilateral rigidity
from pressure on the motor paths (Sharkey).
Diagnosis. — From the general symptoms alone the existence of
tumor may be determined, for the combination of headache, optic neuri-
tis, and vomiting is distinctive. The localization must be gathered from
the consideration of the symptoms above detailed. Mistakes are most
likely to occur in connection with uraemia, hysteria, and general paralysis;
but careful consideration of all the circumstances of the case usually en-
ables thf3 practitioner to avoid error.
Prognosis. — Syphilitic tumors alone are amenable to treatment.
Tuberculous growths occasionally cease to grow and become calcified.
The gliomata and fibromata, particularly when the latter grow from the
membranes, may last for years. I have described a case of small, hard
922 DISEASES OF THE NERVOUS SYSTEM.
glioma, in which the Jacksonian epilepsy persisted for fourteen years.
Hughlings Jackson has reported cases of glioma in which the symptoms
lasted for over ten years. The more rapidly growing sarcomata usually
prove fatal in from six to eighteen months. Death may be sudden, par-
ticularly in growths near the medulla ; more commonly it is due to coma
in consequence of gradual increase in the intracranial pressure.
Treatment. — (a) Medical. — If there is a suspicion of syphilis the
iodide of potassium and mercury should be given. Nowhere do we see more
brilliant therapeutical effects than in certain cases of cerebral gummata.
The iodide should be given in increasing doses. In tuberculous tumors the
outlook is less favorable, though instances of cure are reported, and there
is post-mortem evidence to show that the solitary tuberculous tumors may
undergo changes and become obsolete. A general tonic treatment is indi-
cated in these cases. The headache usually demands prompt treatment.
The iodide of potassium in full doses sometimes gives marked relief. An
ice-cap for the head or, in the occipital headache, the application of the
Paquelin cautery may be tried. The bromides are not of much use in the
headache from this cause, and, as the last resort, morphia must be given.
For 'the convulsions bromide of potassium is of little service.
(b) Surgical. — Tumors of the brain have been successfully removed by
Macewen, Horsley, Keen, and others. The number of cases for operation,
however, is small. Four fifths at least of all the cases are probably un-
successful, or of such a nature as to render an operation fatal. The most
advantageous cases are the localized fibromata growing from the dura and
only compressing the brain substance, as in Keen's remarkable case. The
safety with which the exploratory operation can be made warrants it in
all doubtful cases.
VIII. CHRONIC HYDROCEPHALUS.
Definition. — A condition, congenital or acquired, in which there is
a great accumulation of fluid within the ventricles of the brain.
The term hydrocephalus has also been applied to the collection of fluid
between the cortex of the brain and the skull, known in this situation as
h. externus or ?i. ex vacuo, a condition common in cases of atrophy of the
brain substance, and perhaps caused also by meningeal cysts. A true
dropsy, however, of the arachnoid sac probably does not occur.
The cases may be divided into two groups, congenital or infantile, and
secondary or acquired.
(1) Congenital Hydrocephalus. — The enlarged head may obstruct
labor; more frequently the condition is noticed some time after birth.
The cause is unknown. It has occurred in several members of the same
family.
The anatomical condition in these cases offers no clew to the nature of
CHRONIC HYDROCEPHALUS. 923
the trouble. The hiteral ventricles are enormously distended, but the
ependyma is usually clear, sometimes a little thickened and granular, and
the veins large. 'J'he choroid plexuses are vascular, sometimes sclerotic, but
often natural-looking. The third ventricle is enlarged, the aqueduct of
Sylvius dilated, and the fourth ventricle may be distended. The quantity
of fluid may reach several litres. It is limpid and contains a trace of
albumen and salts. The changes in consequence of this enormous ven-
tricular distention are remarkable. The cerebral cortex is greatly stretched,
and over the middle region the thickness may amount to no more than a
few millimetres without a trace of the sulci or convolutions. The basal
ganglia are flattened. The skull enlarges, and the circumference of the
head of a child of three or four years may reach twenty-five or even thirty
inches. The sutures widen. Wormian bones develop in them, and the
bones of the cranium become exceedingly thin. The veins are marked be-
neath the skin. A fluctuation wave may sometimes be obtained, and
Fisher's brain murmur may be heard. The orbital plates of the frontal
bone are depressed, causing exophthalmos, so that the eyeballs cannot be
covered by the eyelids.
Convulsions may occur. The reflexes are increased, the child learns
to walk late, and ultimately in severe cases the legs become feeble and
sometimes spastic. The mental condition is variable ; the child may be
bright, but, as a rule, there is some grade of imbecility. The congenital
cases usually die within the first four or five years. The process may be
arrested and the patient may reach adult life. Cases of this sort are not
very uncommon. Even when extreme, the mental faculties may be
retained, as in Bright's celebrated patient, Cardinal, who lived to the age
of twenty-nine, and whose head was translucent when the sun was shin-
ing behind him. Care must be taken not to mistake the rachitic head for
hydrocephalus.
(2) Acquired Chronic Hydrocephalus. — This is stated to be occasionally
primary (idiopathic) — that is to say, it comes on spontaneously in the
adult without observable lesion. Dean Swift is said to have died of hydro-
cephalus, but this seems very unlikely. It is based upon the statement
that " he (Mr. Whiteway) opened the skull and found much water in the
brain," a condition no doubt of h. ex vacuo^ due to the wasting associated
with his prolonged illness and paralysis. In nearly all cases there is either
a tumor at the base of the brain or in the third ventricle, which compresses
the venae Galeni. The passage from the third to the fourth ventricle may
be closed, either by a tumor or by parasites. More rarely the foramen of
Magendie, through which the ventricles communicate with the cerebro-
spinal meninges, becomes closed by meningitis. These conditions, occur-
ring in adults, may produce the most extreme hydrocephalus without any
enlargement of the head. Even when the tumor begins early in life there
may be no expansion of the skull. In the case of a girl aged sixteen, blind
from her third year, the head was not unusually large, the ventricles were
924 DISEASES OF THE NERVOUS SYSTEM.
enormously distended, and in the Kolandic region the brain substance was
only five millimetres in thickness. A tumor occupied the third ventricle.
In a case of cholesteatoma of the floor of the third ventricle, in which the
symj)toms persisted at intervals for eight or nine years, the ventricles were
enormously distended without enlargement of the skull. In other in-
stances the sutures separate and the head gradually enlarges.
The symptoms of hydrocephalus in the adult are curiously variable.
In the case first mentioned there were early headaches and gradual blind-
ness; then a prolonged period in which she was able to attend to her
studies. Headaches again supervened, the gait became irregular and
somewhat ataxic. Death occurred suddenly. In the other case there
were prolonged attacks of coma with a slow pulse, and on one occasion the
patient remained unconscious for more than three months. Gradually
progressing optic neuritis without focalizing symptoms, headache, and
attacks of somnolence or coma are suggestive symptoms. Cases are rare
as a result of meningitis. The only instances I have seen were two which
corresponded to the posterior meningitis of Gee and Barlow, in which,
with the distention, there was extensive chronic purulent ependymitis.
Treatment. — Very little can be done to relieve hydrocephalus.
Medicines are powerless to cause the absorption of the fluid. More
rational is the system of gradual compression, with or without the with-
dravv^al of small quantities of the fluid. The compression may be made
by means of broad plasters, so applied as to cross each other on the vertex,
and another may be placed round the circumference.
Of late years puncture of the ventricles, an operation which had been
abandoned, has been revived, particularly by Keen, and in a few cases
is justifiable. When pressure symptoms are marked it may be employed
with great relief to the headache and removal of the spastic state of the
legs. Quincke recommends, and has practised in these cases, as well as
in acute hydrocephalus, puncture of the subarachnoid sac between the
third and the fourth lumbar vertebrae. At this point the spinal cord can-
not be touched. The advantage is a slower removal of fluid and less
danger of collapse.
IV. GEXEEAL AND FUNCTIONAL DISEASES.
I. ACUTE DELIRIUM {BelVs 3Iania).
Definition. — Acute delirium running a rapidly fatal course, with
slight fever, and in which post mortem no lesions are found sufficient to
account for the disease.
Cases are reported by many old writers under the term brain fever or
phrenitis. Bell, at the time Superintendent of the McLean Asylum, dc-
ACUTE DELIRIUM. 925
scribed it * accurately under the designation, " a form of disease resembling
some advanced stages of mania and fever."
The disease may set in abruptly or be preceded by a period of irrita-
bility, restlessness, and insomnia. The mental symptoms develop with
rapidity and may quickly reach a grade of the most intense frenzy. There
are the wildest hallucinations and outbreaks of great violence. The pa-
tient talks incessantly, but incoherently and unintelligibly. No sleep is
obtained, and at last, worn out with the intensity of the muscular move-
ments, the patient becomes utterly prostrated and assumes the sitting or
recumbent posture. There may sometimes be definite salaam movements,
and in a case which I saw at Westphal's clinic the patient incessantly
made motions as if working a pump handle. After a period of intense
bodily excitement, lasting for from twenty-four to thirty-six hours or
longer, the patient can be examined, and presents the conditions which
Bell described as typho-mania. The temperature ranges from 102° to
104°, or even higher. The tongue is dry, the pulse rapid and feeble,
and sometimes there are seen on the skin bullae and pustules, and fre-
quently sores from abrasion and self-inflicted injuries. Toward the close
or, according to Spitzka, even during the development of the disease there
may be lucid intervals. There may be petechise on the skin, and often
there is marked congestion of the face and extremities. The duration of
the disease is variable. Very acute cases may terminate within a week ;
others persist for two or even three weeks. The course of the disease is
almost uniformly fatal. The anatomical condition is practically nega-
tive, or at any rate presents nothing distinctive. There is great venous
engorgement of the vessels of the meninges and of the gray cortex. In
two cases in which I made a careful microscopic examination of the gray
matter there were perivascular exudation and leucocytes in the lymph
sheaths and perigangliar spaces. In the inspection of fatal cases of acute
delirium careful examination should be made of the lungs and ileum. It
should be borne in mind that in a majority of the cases dying in this
manner, there is engorgement of the bases of the lungs or even deglutition
pneumonia.
The nature of the disease is quite unknown. Some of the cases sug-
gest acute infection. Spitzka thinks that it u due to an autochthonous
nerve poison.
Diagnosis. — There are several diseases which may present identical
symptoms. As Bell remarks in his paper, the first glance in many cases
suggests typhoid fever, particularly when the patient is seen after the vio-
lence of the mania subsides. He gives two instances of this which were ad-
mitted from a general hospital. Enlargement of the spleen, the occur-
rence of spots, and the history give clews for the separation of the cases ;
but there are instances in which it is at first impossible to decide. More-
* American Journal of Insanity, 1849.
926 DISEASES OP THE NERVOUS SYSTEM.
over, typhoid fever may set in with the most intense delirium. The exist-
ence of fever is the most deceptive symptom, and its combination with
delirium and dry tongue so commonly means typhoid fever that it is very
difficult to avoid error.
Acute pneumonia may come on with violent maniacal delirium and the
pulmonary symptoms may be entirely masked.
Occasionally acute uraemia sets in suddenly with intense mania, and
finally subsides into a fatal coma. The condition of the urine and the ab-
sence of fever would be important diagnostic features.
The character of the delirium is quite different from that of maiiia a
potic. It may be extremely difficult to differentiate acute delirium from
certain cases of cortical meningitis, which, however, is usually a secondary
affection, occurring in connection with pneumonia or ulcerative endo-
carditis, or is due to extension from disease of the ear. This sets in more
frequently with a chill, and there may be convulsions.
Treatment. — Even though bodily prostration is apt to come on
early and be profound, I would not hesitate to advise, in the case of a
robust man, free venesection. It is not at all improbable that some of the
many cases of mania in which Benjamin Rush let blood with such benefit
belonged to this class of affections. Considering its remarkable calming
influence in febrile delirium, the cold bath or the cold pack should be em-
ployed. Morphia and chloroform may be administered, and hyoscine and
the bromides may be tried. Krafft-Ebing states thaf Solivetti has ob-
tained good results by the use of ergotin. Unfortunately, as asylum re-
ports show, the disease is almost uniformly fatal.
II. PARALYSIS AGITANS
{Parkinson's Disease ; Shalcing Palsy).
Definition. — A chronic affection of the nervous system, characterized
by muscular weakness, tremors, and rigidity.
Etiology. — Men are more frequently affected than women. It rarely
occurs under forty, but instances have been reported in which the disease
began about the twentieth year. It is by no means an uncommon affec-
tion. Direct heredity is rare, but the patients often belong to families in
which there are other nervous affections. Among exciting causes may be
mentioned exposure to cold and wet, and business worries and anxieties.
In some instances the disease has followed directly upon severe mental
shock or trauma. Cases have been described after the specific fevers,
^[alaria is believed by some to be an important factor, but of this there is
no satisfactory evidence.
Morbid Anatomy. — "N"o constant lesions have been found. The
similarity between certain of the features of Parkinson's disease and those
of old age suggest that the affection may depend upon a premature senil-
PARALYSIS AGITANS. 927
ity of certain regions of the brain. Our organs do not age uniformly, but
in some, owing to hereditary disposition, tlie process may be more rapid
than in others. " Parkinson's disease has no characteristic lesions, but on
the other hand it is not a neurosis. It has for an anatomical basis the
lesions of cerebro-spinal senility, and which only differ from those of true
senility in their early onset and greater intensity." (Dubief.) The im-
portant changes are doubtless in the cerebral cortex.
Symptoms. — The disease begins gradually, usually in one or other
hand, and the tremor may be either constant or intermittent. With this
may be associated weakness or stiffness. At first these symptoms may be
present only after exertion. Although the onset is slow and gradual in
nearly all cases, there are instances in which it sets in abruptly after fright
or trauma. When well established the disease is very characteristic, and
the diagnosis can be made at a glance. The four prominent symptoms
are tremor, weakness, rigidity, and the attitude.
Tremor. — This may be in the four extremities or confined to hands or
feet ; the head is not so commonly affected. The tremor is usually marked
in the hands, and the thumb and forefinger display the motion made in the
act of rolling a pill. At the wrist there are movements of pronation and
supination, and less marked of flexion and extension. The upper-arm
muscles are rarely involved. In the legs the movement is most evident at
the ankle-joint, and less in the toes than in the fingers. Shaking of the
head is less frequent, but does occur, and is usually vertical, not rotatory.
The rate of oscillation is about five per second. Any emotion exaggerates
the movement. The attempt at a voluntary movement may check the
tremor (the patient may be able to thread a needle), but it returns with
increased intensity. The tremors cease, as a rule, during sleep, but persist
when the muscles are at repose. The writing of the patient is tremulous
and zigzag.
Weakness. — Loss of power is present in all cases, and may occur even
before the tremor, but is not very striking, as tested by the dynamometer,
until the late stages. The weakness is greatest where the tremor is most
developed. The movements, too, are remarkably slow. There is rarely
complete loss of power.
Rigidity may early be expressed in a slowness and stiffness in the vol-
untary movements, which are performed with some effort and difficulty,
and all the actions of the patient are deliberate. This rigidity is in all the
muscles, and leads ultimately to fhe characteristic
Attitude and Gait. — The head is bent forward, the back is bowed, and
the arms are held away from the body and are somewhat flexed at the
elbow-joints. The face is expressionless, and the movements of the lips
are slow. Tlie eyebrows are elevated, and the whole expresion is immobile
or mask-like, the so-called Parkinson's mask. The voice, as pointed out
by Buzzard, is apt to be shrill and piping, and there is often a hesitancy in
beginning a sentence ; then the words are uttered with rapidity, as if the
928 DISEASES OF THE NERVOUS SYSTEM.
patient was in a hurry. This is sometimes in striking contrast to the scan-
ning speech of insular sclerosis. The fingers are flexed and in the position
assumed when the hand is at rest ; in the late stages they cannot be ex-
tended. Occasionally there is overextension of the terminal phalanges.
The hand is usually turned toward the ulnar side, and the attitude some-
what resembles that of advanced cases of rheumatoid arthritis. In the
late stages there are contractures at the elbows, knees, and ankles. The
movements of the patient are characterized by great deliberation. He
rises from the chair slowly in the stooping attitude, with the head project-
ing forward. In attempting to walk the steps are short and hurried, and,
as Trousseau remarks, he appears to be running after his centre of gravity.
This is termed festination or propulsion, in contradistinction to a peculiar
gait observed when the patient is pulled backward, when he makes a num-
ber of steps and would fall over if not prevented — retropulsion.
The reflexes are normal in most cases, but in a few they are exag-
gerated.
Of sensory disturbances Charcot has noted abnormal alterations in the
temperature sense. The patient may complain of subjective sensations of
heat, either general or local — a phenomenon which may be present on one
side only and associated with an actual increase of the surface tempera-
ture, as much as 6° F. (Gowers). In other instances, patients comj^lain
of cold. Localized sweating may be present. The mental condition rarely
shows any change.
Variations in the Symptoms. — The tremor may be absent, but the
rigidity, weakness, and attitude are sufficient to make the diagnosis. The
disease may be hemiplegic in character, involving only one side or even
one limb. Usually these are but stages of the disease.
Diagnosis. — In well-developed cases the disease is recognized at a
glance. The attitude, gait, stiffness, and mask-like expression are points
of as much importance as the oscillations, and usually serve to separate
the cases from senile and other forms of tremor. Disseminated sclerosis
develops earlier, and is characterized by the nystagmus, and the scanning
speech, and does not present the attitude so constant in paralysis agitans.
The hemiplegic form might be confounded with post-hemiplegic tremor,
but the history, the mode of onset, and the greatly increased reflexes would
be sufficient to distinguish the two. The Parkinsonian face is of great
importance in the diagnosis of the obscure and anomalous forms.
The disease is incurable. Periods of improvement may occur, but the *
tendency is for the affection to proceed progressively downward. It is a
slow, degenerative process and the cases last for years.
Treatment. — There is no method which can be recommended as
satisfactory in any respect. Arsenic, opium, and hyoscyamia may be tried,
but the friends of the patient should be told frankly that the disease is
incurable, and that nothing can be done except to attend to the physical
comforts of the patient.
ACUTE CHOREA. 929
Other Forms of Tremor.
(a) Simple Tremor. — This is occasionally found in persons in whom it
is impossible to assign any cause. It may be transient or persist for an
indefinite time. It is often extremely slight, and is aggravated by all causes
which lower the vitality.
{!)) Hereditary Tremor. — C. L. Dana has reported remarkable cases of
hereditary tremor. It occurred in all the members of one family, and
beginning in infancy it continued without producing any serious changes.
{c) Senile Tremor. — With advancing age tremulousness during mus-
cular movements is extremely common, but is rarely seen under seventy.
It is always a fine tremor, which begins in the hands and often extends to
the muscles of the neck, causing slight movement of the head.
{d) Toxic tremor is seen chiefly as an effect of tobacco, alcohol, lead, or
mercury ; more rarely in arsenical or opium poisoning. In elderly men
who smoke much it may be entirely due to the tobacco. One of the com-
monest forms of this is the alcoholic tremor, which occurs only on move-
ment and has considerable range. Lead tremor will be considered in
speaking of lead poisoning, of which it constitutes a very important
symptom.
(e) Hysterical tremor^ which usually occurs under circumstances which
make the diagnosis easy, will be considered in the section on hysteria.
III. ACUTE CHOREA
{Sydenham'' 8 Chorea ; St. Vitus' s Dance).
Defi.uition. — A disease chiefly affecting children, characterized by
irregular, involuntary contraction of the muscles, a variable amount of
psychical disturbance, and a remarkable liability to acute endocarditis.
We shall speak here only of Sydenham's chorea. Senile chorea, chronic
chorea, the prehemiplegic and post-hemiplegic forms, and rhythmic chorea
are totally different affections.
Etiology. — Sex. — Of 554 cases which I have analyzed from the
Philadelphia Infirmary for Diseases of the Nervous System, seventy-one
per cent were in females and twenty-nine per cent in males. After pu-
berty the percentage in females increases.
Age. — The age incidence in 522 cases was as follows : In the first
decade, 201 ; in the second decade, 248 ; in the third decade, 10 ; in the
fourth decade, 1 ; above the fourth decade, 2. In the cases under twenty
years the following is the age incidence in the hemidecades : In the first
hemidecade, 33 ; in the second hemidecade, 1G8 ; in the third hemi-
decade, 212 ; in the fourth hemidecade, 52.
Station. — While the disease affects children of all grades of society, it
is more common among the lower classes.
930 DISEASES OF THE NERVOUS SYSTEM.
Race. — As shown by inquiries instituted by Weir Mitchell some years
ago, chorea is rare in the negro. No negro child of full birth has been
under treatment at the Pliiladelphia Infirmary. From inquiries made
among the medical men who practise in the Indian Territories and in the
Indian schools in this country, I find that the disease is unknown in the
native races.
Seasonal Relations. — Morris J. Lewis has analyzed 437 separate attacks
with reference to this point. Throughout December, January, and Feb-
ruary the cases increase There is a fall in April, a rise through May and
July, and then a steady fall until October. The cases are most numerous
when the mean relative humidity and barometric pressure are low.
Rheumatism. — A causal relationship between rheumatism and chorea
has been claimed by many since the time of Bright. The English and
French writers maintain the closeness of this connection, and Roger goes
so far as to regard the disease in all cases as a manifestation of rheumatism.
On the other hand, German authors, as a rule, regard the connection as by
no means very close. Discrepancy such as exists between the figures of
Steiner, who found only 4 cases of acute rheumatism in 252 cases of
chorea, and English writers, such as Dickenson, Barlow, and others, w^ho
place the percentage at from fifty to seventy of the cases, can only be ex-
plained on the supposition that the connection varies greatly in different
localities. Of 554 cases wdiich I have analyzed, in 15*5 per cent there was
a history of rheumatism in the family. In 88 cases, 15-8 per cent, there
was a history of articular swelling, acute or subacute. In 3B cases there
were pains, sometimes described as rheumatic, in various parts, but not
associated with joint trouble. If we regard all such cases as rheumatic
and add them to those with manifest articular trouble, the percentage is
raised to nearly twenty-one.
We find two groups of cases in which acute arthritis is present in
chorea. In one, the arthritis antedates by some months or years the onset
of the chorea, and does not recur before or during the attack. In the
other group, the chorea sets in with or follows immediately upon the
acute arthritis. In some instances it is impossible to decide whether
the joint trouble or the movements come first. It is difficult to differen-
tiate the cases of irregular pains without definite joint affection. It is
probable that many of them are rheumatic, and yet I think it would
be a mistake to regard as such all cases in children in which there are
complaints of vague pains in the bones or muscles — so-called growing
pains. It should never be forgotten, however, that a slight articular swell-
ing may be the sole manifestation of rheumatism in a child — so slight in-
deed, that the disease may be entirely overlooked. Tlie statistics of the
Collective Investigation Committee of the British Medical Association,
based upon 439 cases, give twenty-six per cent of antecedent joint affec-
tion, and if the cases of vague pains believed to be rheumatic are added,
the percentage is raised to thirty-two. In this country rhcumatiim is not
ACUTE CHOREA. 931
SO common in children as in England. Of the last 144 cases of the Infirm-
ary series, almost every one of which I saw personally, and in which the
most minute inquiries were made about rheumatism, there were only 25
cases with articular pains or swelling, and in only G had there been acute
inflammatory rheumatism. The question may reasonably be asked. Do
these articular affections of chorea belong to true rheumatism? Are
they not analogous to the joint troubles of scarlet fever, puerperal fever,
and gonorrhcea, which no one now regards as truly rheumatic? They
have been spoken of by French writers as choreic arthropathies.
Heart-disease. — Endocarditis is believed by some writers to be the
cause of the disease. The particles of fibrin and vegetations from the
valves pass as emboli to the cerebral vessels. On this view, which we shall
discuss later, chorea is the result of an embolic process occurring in the
course of a rheumatic endocarditis.
Infectious Diseases. — Scarlet fever with arthritic manifestations may
be a direct antecedent. It may be mentioned that a history of this disease
occurred in 141 cases, or about twenty-five per cent. Sturges states that a
history of previous whooping-cough occurs more frequently in choreic than
in other children, but I find no evidence of this in the Infirmary records.
With the exception of rheumatic fever, there is no intimate relationship
between chorea and the acute diseases incident to childhood. It may be
noted in contrast to this that the so-called canine chorea is a common
sequel of distemper. Chorea has been known to develop in the course of
an acute pyaemia, and to follow gonorrhoea and puerperal fever.
Kinnicutt and others have reported cases of chorea in malarial fevers,
but the association was probably accidental, not causal. Anaemia is less
often an antecedent than a sequence of chorea, and though cases develop
in children who are anaemic and in poor health, this is by no means the
rule. Chorea may develop in chlorotic girls at puberty.
Pregnancy. — Chorea may occur during pregnancy — most often during
the first five months. It is more common in a first pregnancy, and is rare
in women over twenty-five years of age. The disease is usually severe and
maniacal symptoms may develop. Occasionally it comes on after an abor-
tion or after delivery at term.
A tendency to the disease is found in certain families. In eighty cases
there was a history of attacks of chorea in other members. In one instance
both mother and grandmother had been affected. High-strung, excitable,
nervous children are specially liable to the disease. Fright is considered
a frequent cause, but in a large majority of the cases no close connection
exists between the fright and the onset of the disease. Occasionally the
attack sets in at once. Mental worry, trouble, a sudden grief, or a scold-
ing may apparently be the exciting cause. The strain of education^ par-
ticularly in girls during the third hemidecade, is a most important fac-
tor in the etiology of the disease. Bright, intelligent, active-minded
girls from ten to fourteen, ambitious to do well at school, often stimulated
59
932 DISEASES OF THE NERVOUS SYSTEM.
in their efforts by teachers and parents, form a large contingent of the
cases of chorea in hospital and private practice. Sturges has called
special attention to this school-made chorea as one serious evil in our
modern method of forced education. Imitation^ which is mentioned as
an exciting cause, is extremely rare, and does not appear to have influ-
enced the onset in a single case in the Infirmary records.
The disease may rapidly follow an injury or a slight surgical opera-
tion. Reflex irritation was believed to play an important role in the dis-
ease, particularly the presence of worms or genital irritation ; but I have
met with no instance in which the disease could be attributed to either of
these causes. Local spasm, particularly of the face — the habit chorea of
Mitchell — may be associated with irritation in the nostrils and adenoid
growths in the vault of the pharynx, as pointed out by Jacobi.
It has been claimed by Stevens that ocular defects lie at the basis of
many cases of chorea, and that with the correction of these the irregular
movements disappear. To test the truth of these statements a careful
study was made at the Infirmary by De Schweinitz of the condition of the
eyes in 50 cases of chorea in children, with the following results : Hyper-
metropia was present in 23, or forty-six per cent ; hypermetropia in one
eye and hypermetropic astigmatism in the other in 7, or fourteen per cent ;
hypermetropic astigmatism in 12, or twenty-four per cent ; myopia in 1,
or two per cent ; myopic astigmatism in 3, or six per cent ; mixed astig-
matism in 4, or eight per cent. De Schweinitz then adds the cases re-
ported by Stevens and C. S. Bull, of New York, making a total of 227
cases, of which 112 were ametropic and 115 emmetropic. His conclusions
are as follows : " Hypermetropia and hypermetropic astigmatism are vastly
the preponderating condition in the eyes of choreic children, being found
in about seventy-seven per cent of the cases, exactly as hypermetropic re-
fraction is the preponderating condition in childhood, being found in
seventy-six per cent of the eyes of children in the elementary schools," and
the " evidence, however, seems quite as lacking that hypermetropic refrac-
tion is the basal cause of chorea, as it is that the chorea is the cause of the
hypermetropia."
The committee of the New York Neurological Society which investi-
gated with great care and impartiality Stevens's claims came to the con-
clusion that the facts did not warrant their adoption.
Morbid Anatomy and Pathology. — No constant lesions have
been found in tlie nervous system in acute chorea. Vascular changes,
such as hyaline transformation, exudation of leucocytes, minute haemor-
rhages, and thrombosis of the smaller arteries, have been described.
Embolism of the smaller cerebral vessels has often been found, as
might be expected in a disease with which endocarditis is so frequently as-
sociated. Based upon this fact, Kirkes, Tuckwell, Ilughlings Jackson,
and Bastian have supported what is known as the embolic theory of the
disease. Endocarditis is by far the most frequent lesion in Sydenham's
ACUTE CriOREA. 933
chorea. Witli no disease, not excepting rheumatism, is it so constantly
associated. In the records of over 110 autopsies, in nearly 100 this condi-
tion was mentioned. In the 5 autopsies of which I have notes, in all the
mitral valves were affected. The endocarditis is usually of the simple
variety, but the ulcerative form has occasionally been described.
We are still far from a solution of all the problems connected with
chorea. Unfortunately, the word has been used to cover a series of totally
diverse disorders of movement, so that there are still excellent observers
who hold that chorea is only a symptom, and is not to be regarded as an
etiological unit. The chorea of childhood, the disease which Sydenham
described, presents, however, characteristics so unmistakable that it must
be regarded as a definite, substantive affection. We cannot discuss fully,
but only indicate briefly, certain of the theories which have been advanced
with regard to it. The most generally accepted view is that it is a func-
tional brain disorder affecting the nerve-centres controlling the motor
apparatus, an instability of the nerve-cells, brought about, one supposes by
hyperaemia, another by anaemia, a third by psychical influences, a fourth
by irritation, centric or peripheric. Of the actual nature of this derange-
ment we know nothing, nor, indeed, whether the changes are primary and
the result of a faulty action of the cortical cells or whether the impulses
are secondarily disturbed in their course down the motor path. The pre-
dominance of the disease in females, and its onset at a time when the
education of the brain is rapidly developing, are etiological facts which
Sturges has urged in favor of the view that chorea is an expression of
functional instability of the nerve-centres.
The embolic theory originally advanced by Kirkes and supported by
the English writers above mentioned has a solid basis of fact, but it is
not comprehensive enough, as all of the cases cannot be brought within its
limits. There are instances without endocarditis and without, so far as
can be ascertained, plugging of cerebral vessels ; and there are also cases
with extensive endocarditis in which the histological examination of the
brain, so far as embolism is concerned, was negative. In two of my post-
mortems there were certainly no emboli in the smaller arteries of the
branches of the circle of Willis or of the cortex. In the third there was
a spot in one corpus striatum of red softening, probably due to an embolus.
In favor of the embolic view is the experimental production in animals of
chorea by Eosenthal, and later by Money, by injecting fine particles into
the carotids of animals.
Lately, as indeed might be expected, a microbic origin has been sought
for, and, however improbable such a theory looks at first sight, the case
of tetanus gives a warrant, at least, to speculation and investigation in
this direction. Nothing definite has yet been determined. From Nau-
nyn's clinic a case is reported with endocarditis and a reddish-brown
infiltration of the pia at the base of the brain which proved to be a micro-
bic growth similar in character to those in the vegetations on the heart
934 DISEASES OF THE NERVOUS SYSTEM.
valves. Recently, in a fatal case in my wards cultures of a micrococcus
were obtained from the blood of the heart, and throughout the brain there
were minute foci of haemorrhage similar to those which occur in pneu-
monia and other infectious disease associated with endocarditis. In favor
of this view it has been urged, as it is impossible to refer the chorea to
endocarditis or the endocarditis in all cases to rheumatism, that both have
their origin in a common cause, some infectious agent, which is capable
also, in persons predisposed, of exciting articular disease. Cases have been
reported in scarlet fever with arthritic manifestations, in puerperal fever,
and rheumatism, also after gonorrhoea, and such facts are suggestive at
least of the association of the disease with infective processes. Possibly,
as has been suggested by some writers, the paralytic conditions associated
with chorea may be analogous to those which occur in t}q:)lioid and certain
of the infectious diseases. On the other hand, there are conditions ex-
ti'emely difficult to harmonize with this view. The prominent psychical
element is certainly one of the most serious objections, since there can be
no doubt that ordinary chorea may rapidly follow a fright or a sudden
emotion. It cannot be supposed, too, that the forms associated with reflex
irritation, as from the nose and particularly the cases of so-called habit
chorea, can be dependent upon infection. AVe must place these in a sepa-
rate category, and yet in a long series cases shade so imperceptibly into
each other that it is extremely difficult to separate them properly. The
question deserves careful study, and the possibility of a special infectious
agent has of late been advocated by several writers.
Symptoms. — Three groups of cases may be recognized — the mild,
severe, and maniacal chorea.
Mild Chorea. — In this the affection of the muscles is slight, the speech
is not seriously disturbed, and the general health not impaired. Premoni-
tory symptoms are shown in restlessness and inability to sit still, a condi-
tion well characterized by the term " fidgets." There are emotional dis-
turbances, such as crying spells, or sometimes night-terrors. There may
be pains in the limbs and headache. Digestive disturbances and ansemia
may be present. A change in the temperament is frequently noticed,
and a docile, quiet child may become cross and irritable. After these
symptoms have persisted for a week or more the characteristic involun-
tary movements begin, and are often first noticed at the table, when the
child spills a tumbler of water or upsets a plate. There may be only awk-
wardness or slight incoordination of voluntary movements, or constant irreg-
ular clonic spasms. The jerky, irregular character of the movements differ-
entiates them from almost every other disorder of motion. In the mild
cases only one hand, or the hand and face, are affected, and it may not
spread to the other side.
In the second grade, the severe form^ the movements become general
and the patient may be unable to get about or to feed or undress herself,
owing to the constant, irregular, clonic contractions of the various muscle
ACUTE CHOREA. O35
groups. The speech is also affected, and for days the child may not be able
to talk. Often with the onset of the severer symptoms there is loss of
power on one side or in the limb most affected.
The third and most extreme form, the so-called maniacal chorea, or
cliorea insaniens^ is truly a terrible disease, and may develop out of the
ordinary form. A young girl, aged eighteen, was admitted to the ^lont-
real Hospital October 17. She was a waitress at a hotel, and being badly
frightened by two men who were fighting, she dropped a tray of dishes
which she was carrying. A severe reprimand increased her worry and
trouble. The next day she packed her trunk and went home, a distance
of thirty miles. Her father insisted that she should return. At this
time her hands and arms began to twitch in a violent manner. Five
days after the first fright she was admitted. The arms and legs were in
constant motion, jerking in all directions. The face also was affected.
She was rational, but could scarcely speak. On the night of the 19th she
had no sleep, but raved and talked all the time, and the movements were
incessant. On the 20th, 21st, and 22d the condition persisted and grew
worse. The temperature ranged from 101° to 103°, the tongue became
dry and cracked, and she became much exhausted. On the night of the
22d the temperature rose to 105° and death followed, ten days after the
onset of the symptoms. These cases are more common in adult women
and may develop during pregnancy.
Chorea begins, as a rule, in the hands and arms, then involves the face,
and subsequently the legs. The movements may be confined to one side
— hemichorea. The attack begins oftenest on the right side, though oc-
casionally it is general from the outset. One arm and the opposite leg
may be involved. In nearly one fourth of the cases speech is affected ;
when slight this is only an embarrassment or hesitancy, but in other in-
stances it becomes an incoherent jumble. In very severe cases the child
will make no attempt to speak. The inability is in articulation rather
than in phonation. The lips and tongue are concerned in the defect.
Occasionally the inspiratory muscles are involved, even when the speech is
not at all affected, and sobbing and sighing may result. Paroxysms of
panting and of hard expiration may occur, or odd sounds may be pro-
duced. As a rule the movements cease during sleep.
A prominent symptom is muscular weakness, usually no more than a con-
dition of paresis. The loss of power is slight, but the weakness may be shown
by an enfeebled grip or by a dragging of the leg or limping. In his original
account Sydenham refers to the " unsteady movements of one of the legs,
which the patient drags." There may be extreme paresis with but few
movements — the paralytic chorea of Todd. Occasionally a local paralysis
or weakness remains after the attack. Case 229 of the Infirmary series, a
lad of ten, had severe general chorea in September, 1880, with considera-
ble loss of power in the legs. Recovery was slow, and when he returned
in September, 1883, in a second attack of chorea, there was talipes of the
936 DISEASES OF THE NERVOUS SYSTEM.
left foot, which had resulted from paralysis in 1880. In Case 21 a wrist-
drop persisted for two years, the result of a palsy which came on with
chorea. These are probably instances of peripheral neuritis.
A question of some interest is whether choreic spasms extend to the
muscles of organic life. The great gastro-intestinal muscle is never
affected. There are no symptoms which can be referred to anomalous
contractions of the stomach or bowels. The sphincters act normally.
Incontinence of urine occurs occasionally, but it is not noted more fre-
quently, I think, in chorea than in other nervous affections. Spasm of
the bronchial muscles is not found even in severe cases, in which the
respiratory muscles are involved. The pupils are usually dilated, but no
irregular contractions occur. The rapid action and disturbed rhythm of
the heart present nothing peculiar to the disease, and there is no support
for the view that irregular contractions occur in the papillary muscles.
Heart Symptoms. — Neurotic. — As so many of the subjects of chorea
are nervous girls, it is not surprising that a common symptom is rapidly
acting heart. Any emotional disturbance causes at once a marked in-
crease in the number of the beats, and the actions may become irregular
and tumultuous. Irregularity, however, is not so special a feature in
chorea as rapidity. The patients seldom complain of pain about the
heart.
Ilmniic Murmurs. — With anaemia and debility, not uncommon asso-
ciates of chorea in the third and fourth week, we find a corresponding
cardiac condition. The impulse is diffuse, perhaps wavy in thin children.
The carotids throb visibly, and in the recumbent posture there may be
pulsation in the cervical veins. On auscultation a systolic murmur is
heard at the base, perhaps, too, at the apex, soft and blowing in quality.
Endocarditis. — As in rheumatism, so in chorea, acute valvulitis rarely
gives evidence of its presence by symptoms. It must be sought, and clin-
ical experience has shown that it is usually associated with murmurs at
one or other of the cardiac orifices.
For the guidance of the practitioner the following statements may be
made :
(1) In thin, nervous children a systolic murmur of soft quality is ex-
tremely common at the base, particularly at the second left costal carti-
lage, and is probably of no moment.
(2) A systolic murmur of maximum intensity at the apex, and heard
also along the left sternal margin, is not uncommon in anaemic, enfeebled
states, and does not necessarily indicate either endocarditis or insuffi-
ciency.
(3) A murmur of maximum intensity at apex, with rough quality, and
transmitted to axilla or angle of scapula, indicates an organic lesion of
the mitral valve, and is usually associated with signs of enlargement of the
heart.
(4) When in doubt it is much safer to trust to the evidence of eye
ACUTE CnOREA. 937
and hand than to that of the ear. If the apex beat is in the normal posi-
tion, and the area of dulness not increased vertically or to the right of the
sternum, there is probably no serious valvular disease.
(5) The endocarditis of chorea is almost invariably of the simple or
warty form, and in itself is not dangerous ; but it is apt to lead to those
S3lerotic changes in the valve which produce incompetency. Of 110 choreic
patients * examined more than two years after the attack, 54 presented
signs of organic heart-disease.
(6) Pericarditis is an occasional complication of chorea, usually in
cases with well-marked rheumatism.
Sensory Disturbances. — Pain in the affected limbs is not common.
Occasionally there is soreness on pressure. There are cases, usually of
hemichorea, in which pain in the limbs is a marked symptom. Weir
Mitchell has spoken of these as painful choreas. The pain may be quite
apart from any arthritic complications. Tingling and pricking sensations
and numbness are found occasionally. Angesthesia is very uncommon.
Tender points along the lines of emergence of the spinal nerves or along
the course of the nerves of the limbs are rare. The French writers have
compared these to the hysterogenic points in hysteria, and have also de-
scribed in certain cases ovarian tenderness. Headache may be a very
troublesome symptom.
Psychical disturhances are common, though in a majority of the cases
slight in degree. Irritability of temper, marked wilfulness, and emotional
outbreaks may indicate a complete change in the character of the child.
There is deficiency in the powers of concentration, the memory is en-
feebled, and the aptitude for study is lost. Karely there is progressive
impairment of the intellect with termination in actual dementia. Acute
melancholia has been described (Edes). Hallucinations of sight and
hearing may occur. Patients may behave in an odd and strange manner
and do all sorts of meaningless acts. By far the most serious manifesta-
tion of this character is the maniacal delirium, occasionally associated with
the very severe cases — chorea insajiiens. Usually the motor disturbance in
these cases is aggravated, but it has been overlooked and patients have
been sent to an asylum.
The psychical element in chorea is apt to be neglected by the practi-
tioner. It is always a good plan to tell the parents that it is not the
muscles alone of the child which are affected, but that the general irrita-
bility and change of disposition, so often found, really form part of the
disease.
The condition of the reflexes in chorea is usually normal. Sinkler
made observations at the Philadelphia Infirmary in 50 cases with the fol-
lowing results : In 26 the knee-jerk was normal, in 15 it was diminished
in degree, and in 0 it could not be obtained. Trophic lesions rarely occur
* American Journal of the Medical Sciences, 1887, ii.
938 DISEASES OF THE NERVOUS SYSTEM.
in chorea unless, as some writers have done, we regard the joint troubles
as arthropathies occurring in the course of a cerebro-spinal disease.
Fever is not, as a rule, present in chorea unless complications exist.
There may be the most intense and violent movements without any rise
of temperature. I have seen instances, however, in which without appar-
ently any visceral or articular disturbances there was slight daily fever.
H. A. Hare states that in monochorea the temperature on the affected
side may be elevated ; but this is not an invariable rule. Fever is found
with an acute arthritis, when there is marked endocarditis or pericarditis,
though the former may certainly occur with little if any rise in tempera-
ture, and in the cases of maniacal chorea, in which the fever may range
from 102° to 104°.
Cutaneous Affections. — These are not very numerous, and in a major-
ity of the cases are probably due to arsenic. There may be an erythema-
tous papular rash. A very interesting condition is the pigmentation
which has been found in patients who have been taking arsenic for
some time. Herpes zoster occasionally occurs. It was noted twice in
the Infirmary records. Certain skin eruptions, usually regarded as rheu-
matic in character, are not uncommon. Thus, erythema nodosum has
been described and I have seen several cases with a purpuric urticaria.
There may, indeed, be the more aggravated condition of rheumatic pur-
pura, known as Schonlein's ][)eliosis rlieumatica. Subcutaneous fibrous
nodules, which have been noted by English observers in many cases of
chorea, associated with rheumatism, are extremely rare in this country. I
have not seen an instance in a choreic patient nor is there a reference in
the Infirmary records to a case. This has not been because they were
not looked for, as I have seen many instances since my attention was called
to them in 1881 by Barlow at the Great Ormond Street Children's Hospital.
They are certainly less common in this country than in England. In the
chorea returns of the Collective Investigation Committee there were 12
cases out of 439. Cheadle states that they are not uncommon in chorea.
Duration and Termination. — From eight to ten weeks is the
average duration of an attack of moderate severity. Cases may be so mild
as to get well in two or three weeks ; on the other hand, there may be
found at every clinic for diseases of the nervous system choreic patients
who have been under treatment for three, four, or even six months.
Chronic chorea rarely follows the minor disease which we have been con-
sidering. The cases described under this designation in children are
usually instances of cerebral sclerosis or Friedreich's ataxia; but occa-
sionally an attack which has come on in the ordinary way persists for
months or years, and recovery ultimately takes place. A slight grade of
chorea, particularly noticeable under excitement, may persist for months
in nervous children.
The tendency of chorea to recur has been noticed by all writers since
Sydenham first made the observation. Of 410 cases analyzed for this pur-
ACUTE CHOREA. 939
pose, 240 had one attack, 110 had two attacks, 35 three attacks, 10 four
attacks, 12 five attacks, and 3 six attacks. The recurrence is apt to be
vernal. Rheumatism seems to favor this tendency ; of GO cases in which
there were three or more attacks, there was a history of articular disease
in 11, a much higher percentage than in cases with only one or two at-
tacks. The occurrence of heart-disease has been thought to increase this
liability, but I think it is the other way — recurrences tend to induce endo-
carditis and valvular disease. Gowers mentions a case with nine recur-
rences without history of rheumatism in which there were signs of mitral
constriction.
Recovery is the rule in children. The statistics of out-patients' depart-
ments are not favorable for determining the mortality. A reliable esti-
mate is that of the Collective Investigation Committee of the British
Medical Association, in which 9 deaths were reported among 439 cases,
about two per cent.
The paralysis rarely persists. Mental dulness may be present for a
time, but usually passes away ; permanent impairment of the mind is an
exceptional sequence.
Diagnosis. — There are few diseases which present more character-
istic features, and in a majority of instances the nature of the trouble is
recognized at a glance ; but there are several affections in children which
may simulate and be mistaken for it.
(a) Multiple and diffuse cerebral sclerosis. Cases such as the follow-
ing are often mistaken for ordinary chorea, and have been described in
literature as chorea spastica : Kellie P., aged nine years, when two years old
had fits which recurred constantly for twenty-one days and persisted on and
off with great severity for nine months ; she never developed satisfactorily ;
she learned to talk, but gradually began to have irregular movements. In
the ninth year the condition was as follows : Speech hesitating ; is unable
to sit, stand, or feed herself ; can move every muscle of the body, but in
an irregular, incoordinate way, which prevents her from using any group
of muscles. In attempting to grasp an object the fingers are thrown out
in a stiff, spasmodic manner, and she is unable to close them over the
object.
In such cases, which are not very uncommon, there are doubtless
chronic changes in the cortex. As a rule, the movements are readily dis-
tinguishable from those of true chorea, but the simulation is sometimes
very close ; the onset in infancy, the impaired intelligence, increased re-
flexes, and in some instances rigidity and the chronic course of the disease,
separate tliem sharply from true chorea.
{b) Friedreich's ataxia. Cases of this well-characterized disease were
formerly classed as chorea. The slow, irregular, incoordinate movements,
tlie scoliosis, scanning speech, the early talipes, the nystagmus, and the
family character of the disease are points which should render the diag-
nosis easy.
940 DISEASES OF THE NERVOUS SYSTEM.
(c) lu rare cases the paralytic form of chorea may be mistaken for
polio-myelitis or, when both legs are affected, for paraplegia of spinal
origin ; bnt this can only be the case when the choreic movements are very
slight. I have at present under my care a young girl with chorea and
loss of power in both legs, who was sent to the hospital as an instance
of paraplegia due to spinal disease, but the choreic movements were dis-
tinct though slight, and a few days' observation sufficed to render clear the
nature of the case.
(d) Hysteria may simulate chorea minor most closely, and unless there
are other manifestations it may be impossible to make a diagnosis. Most
commonly, however, the movements in the so-called hysterical chorea are
rhythmic and differ entirely from those of ordinary chorea.
(e) As mentioned above, the mental symptoms in maniacal chorea may
mask the true nature of the disease and patients have even been sent to
the asylum.
Treatment. — Abnormally bright, active-minded children belonging
to families with pronounced neurotic taint should be carefully watched
from the ages of eight to fifteen and not allowed to overtax their mental
powers. So frequently in children of this class does the attack of chorea
date from the worry and stress incident to school examinations that the
competition for prizes or places should be emphatically forbidden.
The treatment of the attack consists largely in attention to hygienic
measures, with which alone, in time, a majority of the cases recover. Par-
ents should be told to scan gently the faults and waywardness of choreic
children. The psychical element, strongly developed in so many cases,
is best treated by quiet and seclusion. The child should be confined to
bed in the recumbent posture and mental as well as bodily quiet enjoined.
In private practice this is often impossible, but with well-to-do patients
the disease is always serious enough to demand the assistance of a skilled
nurse. Toys and dolls should not be allowed at first, for the child should
be kept amused without excitement. The rest allays the hyper-excitabil-
ity and reduces to a minimum the possibility of damage to the valve seg-
ments should endocarditis exist. Time and again have I seen very severe
cases which had resisted treatment for weeks outside a hospital become quiet
and the movements subside after two or three days of absolute rest in bed.
The child should be kept apart from other children and, if possible,
from other members of the family, and should see only those persons
directly concerned with the nursing of the case. Though irksome and
troublesome to carry out, this is an important part of the treatment. In
the latter period of the disease daily rubbings may be resorted to with
great benefit.
The medicinal treatment of the disease is unsatisfactory ; with the
exception of arsenic, no remedy seems to have any influence in con-
trolling the progress of the affection. Without any specific action, it
certainly does good in many cases, probably by improving the general
ACUTE CnOREA. 941
nutrition. It is conveniently given in the form of Fowler's solution, and
the good effects are rarely seen until maximum doses are taken. Children
stand the drug so well that I usually begin with five minims three times a
day, and after three days increase the dose by one minim each day. When
the dose of fifteen minims is reached, it may be continued for a week, and
then again increased, if necessary, every day or two, until physiological
effects are manifest. On the occurrence of these the drug should be stopped
for three or four days. The practice of resuming the administration with
smaller doses is rarely necessary, as tolerance is usually established and we
can begin with the dose which the child was taking when the symptoms of
saturation occurred. I have frequently given as much as twenty-five min-
ims three times a day. Usually the signs of saturation are trivial but plain,
and I have never seen any ill effects from the large doses, but I have heard
recently of a case of arsenical neuritis due to the administration of Fowler's
solution in chorea.
Of other medicines, strychnine, the zinc compounds, nitrate of silver,
bromide of potassium, belladonna, chloral, and especially cimicifuga, have
been recommended, and may be tried in obstinate cases.
For its tonic effect electricity is sometimes useful ; but it is not neces-
sary as a routine treatment. The question of gymnastics is an important
one. Early in the disease, when the movements are active, it is not ad-
visable ; but during convalescence carefully graduated exercises are un-
doubtedly beneficial. It is not well, however, to send a choreic child to a
school gymnasium, as the stimulus of the other children and the excite-
ment of the romping, violent play is very prejudicial.
Other points in treatment may be mentioned. It is important to regu-
late the bowels and to attend carefully to the digestive functions. For
the anaemia so often present preparations of iron are indicated.
In the severe cases with incessant movements, sleeplessness, dry tongue,
and delirium, the important indication is to procure rest, for which pur-
pose chloral may be freely given, and, if necessary, morphia. Chloroform
inhalations may be necessary to subdue the intensity of the paroxysms,
but the high rate of mortality in this class of cases illustrates how often
our best endeavors are fruitless. The wet pack is sometimes very sooth-
ing and should be tried. As these patients are apt to sink rapidly into a
low typhoid state with heart weakness, a supporting treatment is required
from the outset.
Cases are found now and then which drag on from month to month
without getting either better or worse and resist all modes of treatment.
Change of air and scene is sometimes followed by rapid improvement, and
in these cases the treatment by rest and seclusion should always be given a
full trial.
In all cases care should be taken to examine the nostrils, and glaring
ocular defects should be properly corrected either by glasses or, if neces-
sary, by operation.
942 DISEASES OF THE NERVOUS SYSTEM.
After the child has recovered from the attack, the parents should be
warned tliat return of the disease is by no means infrequent, and is par-
ticularly liable to follow overwork at school or debilitating influences of
any kind. These relapses are apt to occur in the spring. Sydenham ad-
vised purging in order to prevent the vernal recurrence of the disease.
IV. OTHER AFFECTIONS DESCRIBED AS CHOREA.
(a) Chorea Major; Pandemic Chorea. — The common name, St. Vitus's
dance, applied to chorea has come to us from the middle ages, when
under the influence of religious fervor there were epidemics characterized
by great excitement, gesticulations, and dancing. For the relief of these
symptoms, when excessive, pilgrimages were made, and, in the Khenish
provinces, particularly to the Chapel of St. Vitus in Zebern. Epidemics
of this sort have occurred also during this century, and descriptions of
them among the early settlers in Kentucky have been given by Robertson
and Yandell. It was unfortunate that Sydenham applied the term chorea
to an affection in children totally distinct from this chorea major, which
and is in reality an hysterical manifestation under the influence of relig-
ious excitement.
(b) Habit Spasm (Habit Chorea) ; Convulsive Tic (of the French).
Two groups of cases may be recognized under the designation of habit
spasm — one in which there is simply localized spasmodic movements, and
the other in which, in addition to this, there are explosive utterances and
psychical symptoms, a condition to which French writers have given the
name tic coiivitlsif.
(1) Habit Spas7n. — This is found chiefly in childhood, most frequently
in girls from seven to fourteen years of age (Mitchell). In its simplest
form there is a sudden, quick contraction of certain of the facial muscles,
such as rapid winking or drawing of the mouth to one side, or the neck
muscles are involved and there are unilateral movements of the head.
The head is given a sudden, quick shake, and at the same time the eyes
wink. A not infrequent form is the shrugging of one shoulder. The
grimace or movement is repeated at irregular intervals, aiid is much aggra-
vated by emotion. A short inspiratory sniff is not an uncommon symp-
tom. The cases are found most frequently in children who are " out of
sorts," or who have been growing rapidly, or who have inherited a tend-
ency to neurotic disorders. Allied to or associated with this are some of
the curious tricks of children. A boy at my clinic was in the habit every
few moments of putting the middle finger into the mouth, biting it, and
at the same time pressing his nose with tlie forefinger. Hartley Cole-
ridge is said to have had a somewhat similar trick, only he bit his arm.
In all these cases the habits of the cliild should be examined carefully, the
nose and vault of the pharynx thoroughly inspected, and the eyes accurately
OTHER AFFECTIONS DESCRIBED AS CHOREA. 943
tested. As a rule the condition is transient, and after persisting for a few
months or longer gradually disappears. Occasionally a local spasm persists
— twitching of the eyelids, or the facial grimace.
(2) Tic Convulsif (Gilles de la Tourette's Disease^. — This remarkable
affection, often mistaken for chorea, more frequently for habit spasm,
is really a psychosis allied to hysteria, though in certain of its aspects it
has the features of monomania. The disease begins, as a rule, in young
children, occurring as early as the sixth year, though it may develop after
puberty. There is usually a markedly neurotic family history. The
special features of the complaint are :
{a) Involuntary muscular movements, usually affecting the facial or
brachial muscles, but in aggravated cases all the muscles of the body may
be involved and the movements may be extremely irregular and violent.
{h) Explosive utterances, which may resemble a bark or an inarticulate
cry. A word heard may be mimicked at once and repeated over and over
again, usually with the involuntary movements. To this the term echo-
lalia has been applied. A much more distressing disturbance in these
cases is copi^olalia, or the use of bad language. A child of eight or ten
may shock its mother and friends by constantly using the word da7mi
when making the involuntary movements, or by uttering all sorts of ob-
scene words. Occasionally actions are mimicked — eclioJcwiesis.
{c) Associated with some of these cases are curious mental disturb-
ances ; the patient becomes the subject of a form of obsession or a fixed
idea. I was consulted recently about a young girl in whom the spasms
were very slight, amounting only to twitching of the eyes and slight jerk-
ing of the shoulder, but who had a most pronounced grade of the fixed idea
known as aritlimomania. Almost every action, even the most trifling,
was preceded by the counting of a certain number of figures. Before she
went to bed she had to tap her heel upon the side of the bedstead a cer-
tain number of times ; before drinking the tumbler had to be rotated
eight or ten times, and then when set down again the same act was re-
peated. Before opening the door a certain number of knocks had to be
given. The greatest difficulty was experienced in getting her to brush
her hair, as it took her so long to count the necessary number of figures
before she began. In other cases the fixed idea takes the form of the im-
pulse to touch objects. According to Guinon, who has written an ex-
haustive article upon it in the Dictionnaire Encyclopedique, the prognosis
is bad.
The disease is well marked and readily distinguished from ordinary
chorea. The movements have a larger range and are explosive in charac-
ter. Tourette regards the coprolalia as the most distinctive feature of the
disease.
{c) Saltatoric Spasm {TAita; Myrlachit ; Jumjjers). — Bamberger has
described a disease in which when the patient attempted to stand there
were strong contractions in the leg muscles, which caused a jumping or
944 DISEASES OF THE NERVOUS SYSTEM.
springing motion. Tliis occurs only when the patient attempts to stand.
The affection has occurred in both men and women, more frequently in the
former, and the subjects have usually shown marked neurotic tendencies.
In many cases the condition has been transitory ; in others it has per-
sisted for years. Remarkable affections similar to this in certain points
occur as a sort of endemic neurosis. One of the most striking of these
occurs among the " jumping Frenchmen " of Maine and Canada. As de-
scribed by Beard and Thornton, the subjects are liable on any sudden emo-
tion to jump violently and utter a loud cry or sound, and will obey any
command or imitate any action without regard to its nature. The con-
dition of echolalia is present in a marked degree. The " jumping " pre-
vails in certain families.
A very similar disease prevails in parts of Russia and in Java, where it is
known by the names of myriachit and lata, the chief feature of which is
mimicry by the patient of everything he sees or hears.
• (d) Chronic Chorea {Huntingdon'' s Chorea). — An affection character-
ized by irregular movements, disturbance of speech, and gradual dementia.
It is frequently hereditary. The disease has no connection with Sydenham's
chorea, and it is unfortunate that the term was applied to it. It was de-
scribed by Huntingdon, of Pomeroy, Ohio, at the time a practitioner on
Long Island, and he gave in three brief paragraphs the salient points in
connection with the disease — namel}^, the hereditary nature, the associa-
tion with psychical troubles, and the late onset — between the thirtieth and
fortieth years. The disease seems common in this country, and many
cases have been reported by Clarence King, Sinkler, and others.* I have
seen it in two Maryland families within the past two years. Under the
term chronic chorea may be grouped the hereditary form and the
cases which come on without family disposition, either at middle life or,
more commonly, in the aged — senile chorea. It is doubtful whether the
cases in children with chronic choreiform movements, often with mental
weakness and spastic condition of the legs, should go into this category.
The hereditary character of the disease is very striking, and it has been
traced through four or five generations. Huntingdon's father and grand-
father, also physicians, had treated the disease in the family which he de-
scribed. An identical affection occurs without any hereditary disposition.
The age of onset is late, rarely before the thirtieth or the thirty-fifth year.
The symptoms are very characteristic. The irregular movements are
usually first seen in the hands, and the patient has slight difficulty in per-
forming delicate manipulations or in writing. When well established the
movements are disorderly, irregular, incoordinate rather than choreic, and
have not the sharp, brusque motion of Sydenham's chorea. In the face
there are slow, involuntary grimaces. In a well-developed case the gait is
irregular, swaying, and somewhat like that of a drunken man. The speech
* For complete literature, see Huet, de la Choree Chrouique, Paris, 1889.
INFANTILE CONVULSIONS. 945
is slow and diflficult, the syllables are badly pronounced and indistinct, but
not definitely staccato. The mental impairment is a gradual enfeeblement,
leading finally to dementia. At first the patient may be emotional.
Very few post-mortems have been made. No characteristic lesions have
been found. Atrophy of the convolutions, chronic meningo-encephalitis,
and vascular changes have usually been present, the conditions which one
would expect to find in a chronic dementia. These existed in an autopsy
which I have on one of my cases. The affection is evidently a neuro-
degenerative disorder, and has no connection with the simple chorea of
childhood.
(e) Rhythmic or Hysterical Chorea. — This is readily recognized by the
rhythmical character of the movements. It may affect the muscles of the
abdomen, producing the salaam convulsion, or involve the sterno-mastoid,
producing a rhythmical movement of the head, or the psoas, or any group
of muscles. In its orderly rhythm it resembles the canine chorea.
V. INFANTILE CONVULSIONS {Eclampsia).
Convulsive seizures similar to those of epilepsy are not infrequent in
children and in adults. The fit may indeed be identical with epilepsy,
from which the condition differs in that when the cause is removed there
is no tendency for the fits to recur. Occasionally, however, the convul-
sions in children continue and develop into true epilepsy.
Etiology. — A convulsion in a child may be due to many causes, all
of which lead to an unstable condition of the nerve-centres, permitting of
sudden, excessive and temporary nervous discharges. The following are
the most important of them :
(1) Debility, resulting usually from gastro-intestinal disturbance. Con-
vulsions frequently supervene toward the close of an attack of entero-
colitis and recur, sometimes proving fatal. Morris J. Lewis has shown
that the death rate in children from eclampsia rises steadily with that of
gastro-intestinal disorders.
(2) Peripheral irritation. Dentition alone is rarely a cause of convul-
sions, but is often one of several factors in a feeble, unhealthy infant.
The greatest mortality from convulsions is during the first six months, be-
fore the teeth really cut through the gums. Other irritative causes are
the overloading of the stomach with indigestible food. It has been sug-
gested that some of these cases are toxic, owing to the absorption of poi-
sonous ptomaines. Worms, to which convulsions are so frequently attrib-
uted, probably have little influence. Among other sources possible are
phimosis and otitis.
(3) Rickets. The observation of Sir William Jenner upon the associa-
tion of rickets and convulsions has been amply confirmed. The spasms
may be laryngeal, the so-called child-crowing, which, though convulsive in
946 DISEASES OF THE NERVOUS SYSTEM.
nature, can scarcely be considered Avith eclampsia. The influence of this
condition is more apparent in Europe than in this country, although
rickets is a common disease, particularly among the colored people.
Spasms, local or general, in rickets are probably associated with the con-
dition of debility and malnutrition and with cranio-tabes.
(4) Fever. In young children the onset of the infectious diseases is
frequently with convulsions, which often take the place of a chill in the
adult. It is not known upon what they depend. Scarlet fever, measles,
and pneumonia are most often preceded by convulsions.
(5) Congestion of the brain. That extreme engorgement of the blood-
vessels may produce convulsions is shown by their occasional occurrence
in severe whooi^ing-cough, but their rarity in this disease really indi-
cates how small a part mechanical congestion plays in the production
of fits.
(G) Severe convulsions usher in or accompany many of the serious dis-
eases of the nervous system in children. In more than fifty per cent of
the cases of infantile hemiplegia the affection follows severe convulsions.
They less frequently precede a spinal paralysis. They occur with menin-
gitis, tuberculous or simple, and with tumors and other lesions of the
brain.
And, lastly, convulsions may occur immediately after birth and per-
sist for weeks or months. In such instances there has probably been
meningeal haemorrhage or serious injury to the cortex.
The most important question is the relation of convulsions in children
to true epilepsy. In Gowers's figures of 1,450 cases of epilepsy, the attacks
began in 180 during the first three years of life. Of 460 cases of epilepsy
in children which I have analyzed, in 187 the fits began within the first
three years. Of the total list the greatest number, 74, was in the first
year. In nearly all these instances there was no interruption in the con-
vulsions. That convulsions in early infancy are necessarily followed by
epilepsy in after life is certainly a mistake.
Symptoms. — The attack may come on suddenly without any warn-
ing ; more commonly it is preceded by a stage of restlessness, accompanied
by twitching and perhaps grinding of the teeth. It is rarely so complete
in its stages as true epilepsy. The spasm begins usually in the hands,
most commonly in the right hand. The eyes are fixed and staring or are
rolled up. The body becomes stiff and breathing is suspended for a
moment or two by tonic spasm of the respiratory muscles, in consequence
of which the face becomes congested. Clonic convulsions follow, the eyes
are rolled about, the hands and arms twitch, or are flexed and extended in
rhythmical movements, the face is contorted, and the head is retracted.
The attack gradually subsides and the child sleeps or passes into a state of
stupor. Following indigestion the attack may be single, but in rickets and
intestinal disorders it is apt to be repeated. Sometimes the attacks fol-
low each other with great rapidity, so that the child never rouses but dies
INFANTILE CONVULSIONS. 947
in a deep coma. If the convulsion has been limited chiefly to one side
there may be slight paresis after recovery, or in instances in which the
convulsions usher in infantile hemiplegia, when the child arouses one side
is completely paralyzed. During the fit the temperature is often raised.
Death rarely occurs from the convulsion itself, except in debilitated chil-
dren or when the attacks recur with great frequency. In the so-called
hydrocephaloid state in connection with protracted diarrhoea convulsions
may close the scene.
Diagnosis. — Coming on when the subject is in full health, the at-
tack is probably due either to overloaded stomach, to some peripheral
irritation, or occasionally to trauma. Setting in with high fever and
vomiting, it may indicate the onset of an exanthem, or occasionally be the
primary symptom of encephalitis, or whatever the condition is which
causes infantile hemiplegia. AYhen the attack is associated with debility
and with rickets the diagnosis is easily made. The carpopedal spasms
and pseudo-paralytic rigidity which are often associated with rickets,
laryngismus stridulus, and the hydrocephaloid state are usually confined
to the hands and arms and are intermittent and usually tonic. The con-
vulsions associated with tumor or which follow infantile hemiplegia are
usually at first Jacksonian in character. After the second year convulsive
seizures which come on irregularly without apparent cause and recur
while the child is apparently in good health are likely to prove true epi-
lepsy.
Prognosis. — Convulsions play an important part in infantile mor-
tality. In Morris J. Lewis's table of deaths in children under ten, 8*5 per
cent were ascribed to convulsions. West states that 22*35 per cent of
deaths under one year are caused by convulsions, but this is too high an
estimate for this country. In chronic diarrhoea convulsions are usually
of ill omen. Those ushering in fevers are rarely serious, and the same
may be said of the fits associated with indigestion and peripheral irrita-
tion.
Treatment. — Every source of irritation should be removed. If as-
sociated with indigestible food, a prompt emetic should be given, followed
by an enema. The teeth should be examined, and if the gum is swollen,
hot, and tense, it may be lanced ; but never if it looks normal. When
seen at first, if the paroxysm is severe, no time should be lost by giving
a hot bath, but chloroform should be given at once, and repeated if neces-
sary. A child is so readily put under chloroform and with such a small
quantity that this precedure is quite harmless and saves much valuable
time. The practice is almost universal of putting the child into a warm
bath, and if there is fever the head may be douched with cold water. The
temperature of the bath should not be above 95° or 9G°. The very hot
bath is not suitable, particularly if the fits are due to indigestion. After
the attack an ice-cap may be placed upon the head. If there is much irri-
tability, particularly in rickets and in severe diarrhoea, small doses of
60
94:8 DISEASES OF THE NERVOUS SYSTEM.
opium will be found efficacious. When the convulsions recur after the child
comes from under the influence of chloroform it is best to place it rapidly
under the influence of opium, which may be given as morphia hypodemically,
in doses of from one twenty-fifth to one thirtieth of a grain for a child of
one year. Other remedies recommended are chloral by enema, in five-grain
doses, and nitrite of amyl. After the attack has passed the bromides are
useful, of which five to eight grains may be given in a day to a child a
year old. Recurring convulsions, particularly if they come on without
special cause, should receive the most thorough and careful treatment
with bromides. "When associated with rickets the treatment should be
directed to improving the general condition.
VI. EPILEPSY.
Definition. — An affection of the nervous system characterized by
attacks of unconsciousness, with or without convulsions.
The transient loss of consciousness without convulsive seizures is known
as petit mal ; the loss of consciousness with general convulsive seizures is
known as grand mal. Localized convulsions, occurring usually without
loss of consciousness, are known as epileptiform, or more frequently as
Jacksonian or cortical epilepsy.
Etiology. — Age. — In a large proportion of all cases the disease begins
before puberty. Of the 1,450 cases observed by Gowers, in 422 the disease
began before the tenth year, and three fourths of the cases began before
the twentieth year. Of 460 cases of epilepsy in children which I have
analyzed * the age of onset in 427 was as follows : First year, 74 ; second
year, G2 ; third year, 51 ; fourth year, 24 ; fifth year, 17 ; sixth year, 18 ;
seventh year, 19 ; eighth year, 23 ; ninth year, 17 ; tenth year, 27 ; eleventh
year, 17 ; twelfth year, 18 ; thirteenth year, 15 ; fourteenth year, 21 ; fif-
teenth year, 34. Arranged in hemidecades the figures are as follows :
From the first to the fifth year, 229 ; from the fifth to the tenth year, 104 ;
from the tenth to the fifteenth year, 95. These figures illustrate in a
striking manner the early onset of the disease in a large proportion of the
cases. It is well always to be suspicious of epilepsy developing in the
adult, for in a majority of such cases the convulsions are due to a local
lesion.
Sex. — No special influence appears to be discoverable in this relation,
certainly not in children. Of 433 cases in my tables, 232 were males and
203 were females, showing a slight predominance of the male sex. After
puberty unquestionably, if a large number of cases are taken, the males
* Three hundred and nine cases from the records from the Philadelphia Infirmary for
Diseases of the Nervous System, 126 cases at the Elwyn Institution for Feeble-minded
Children, and 25 from the records of my neurological clinic at the Johns Hopkins
Hospital.
EPILEPSY. 949
are in excess. The figures of Sieveking and Reynolds show that tlie dis-
ease is rather more prevalent in females than in males.
Heredity. — Much stress has been laid upon this by many authors as an
important predisposing cause, and the statistics collected give from nine to
over forty per cent. Gowers gives thirty-five per cent for his cases, which
have special value apart from other statistics embracing large numbers
of epileptics in that they were collected by him in his own practice.
In our figures it appears to play a minor role. In the Infirmary list
there were only 31 cases in which there was a history of marked neurotic
taint, and only three in which the mother herself had been epileptic. In
the Elwyn cases, as might be expected, the percentage is larger. Of the
126 there was in 32 a family history of nervous derangement of some sort,
either paralysis, epilepsy, marked hysteria, or insanity. It is interesting
to note that in this group, in which the question of heredity is carefully
looked into, there were only two in which the mother had had epilepsy,
and not one in which the father had been affected. Indeed, I was not a
little surprised to find in the list of my cases that hereditary influences
played so small a part. I have heard this opinion expressed by certain
French physicians, notably Marie, who in writing also upon the question
takes strong grounds against heredity as an important factor in epilepsy.
While, then, it may be said that direct inheritance is comparatively un-
common, the children of neurotic families in which neuralgia, insanity,
and hysteria prevail are more liable to fall victim to the disease.
Chronic alcoholisr)i in the parents is regarded by many as a potent pre-
disposing factor in the production of epilepsy. Echeverria has analyzed
572 cases bearing upon this point and divided them into three classes, of
which 257 cases could be traced directly to alcohol as a cause ; 126 cases
in which there were associated conditions, such as sjrphilis and trauma-
tism ; 189 cases in which the alcoholism was probably the result of the
epilepsy. Figures equally strong are given by Martin,* who found in 150
insane epileptics 83 with a marked history of parental intemperance. Of
the 126 Elwyn cases, in which the family history on this point was care-
fully investigated, in the majority of instances alcoholism seems not to
have existed to any marked degree in the parents, a definite statement be-
ing found in only four of the cases.
Syphilis. — This in the parents is probably less a predisposing than an
actual cause of epilepsy, which is the direct outcome of local cerebral
manifestations. There is no reason for recognizing a special form of
syphilitic epilepsy. On the other hand, convulsive seizures due to acquired
syphilitic disease of the brain are very common.
Of exciting causes fright is believed to be important, but is less so, I
think, than is usually stated. Trauma is present in a certain number of
instances. An important group depends upon a local disease of the brain
* Annales Mcdicales Psychologiques, 1879.
950 DISEASES OF THE NERVOUS SYSTEM.
existing from childhood, as seen in the post-hemiplegic epilepsy. Occa-
sionally cases follow the infectious fevers. Masturbation has been stated
to be a special cause, but its influence is probably overrated. A large
group of convulsive seizures allied to epilepsy are due to some toxic agent,
as in lead-poisoning and in uraemia. Great stress was laid upon reflex
causes, such as dentition and worms, the irritation of a cicatrix, some local
affection, such as adherent prepuce, or a foreign body in the ear or the
nose. In many of these cases the fits cease after the removal of the cause,
so that there can be no question of the association between the two. In
others the attacks persist. Genuine cases of reflex epilepsy are, I believe,
rare. A remarkable instance of it occurred at the Philadelphia Infirmary
for Diseases of the Nervous System in the case of a man with a testis in the
inguinal canal, pressure upon which would cause a typical fit. Removal of
the organ was followed by cure.
Epile2')sy has been thought to be associated with disturbance of the
heart's action, and some have spoken of a special cardiac epilepsy, par-
ticularly in cases in which there is palpitation or slowing of the action
prior to the onset. Epileptic seizures may occur during the passage of a
gall-stone or occasionally during the removal of pleuritic fluid. Indiges-
tion and gastric troubles are extremely common in epilepsy, and in many
instances the eating of indigestible articles seems to precipitate an attack.
An attempt to associate genuine epilepsy with eye-strain has signally
failed.
Symptoms. — (1) Grand Mai. — Preceding the fits there is usually a
localized sensation, known as an aura^ in some part of the body. This
may be somatic, in which the feeling comes from some particular region
in the periphery, as from the finger or hand, or is a sensation felt in the
stomach or about the heart. The peripheral sensations preceding the fit
are of great value, particularly those in which the aura always occurs in a
definite region, as in one finger or toe. It is the equivalent of the signal
symptom in a fit from a brain tumor. The varieties of these sensations
are numerous. The epigastric sensations are most common. In these the
patient complains of an uneasy sensation in the epigastrium or distress in
the intestines, or the sensation may not be unlike that of heart-burn and
may be associated with palpitation. These groups are sometimes known
as pneumogastric aurae or warnings.
Of psychical aurae one of the most common, as described by Hughlings
Jackson, is the vague, dreamy state, a sensation of strangeness or some-
times of terror. The aurae may be associated with special senses, of which
the visual are the most common, consisting of flashes of light or sensa-
tions of color; less commonly, distinct objects are seen. The auditory
aurae consist of noises in the ear, odd sounds, musical tunes, or occasionally
voices. Olfactory and gustatory aurae, unpleasant tastes and odors, are
rare.
Occasionally the fit may be preceded not by an aura, but by certain
EPILEPSY. 951
movements ; the patient may turn round rapidly or run with great speed
for a few minutes, the so-called epilepsia procursiva. In one of the Elwyn
cases the lad stood on his toes and twirled with extraordinary rapidity, so
that his features were scarcely recognizable. At the onset of the attack
the patient may give a loud scream or yell, the so-called epileptic cry.
The patient drops as if shot, making no effort to guard the fall. In
consequence of this, epileptics frequently injure themselves, cutting the
face or head or burning themselves. In the attack, as described by
Hippocrates, " the patient loses his speech and chokes, and foam issues
from the mouth, the teeth are fixed, the hands are contracted, the eyes
distorted, he becomes insensible, and in some cases the bowels are affected.
And these symptoms occur sometimes on the left side, sometimes on the
right, and sometimes on both." The fit may be described in three
stages :
(a) Tonic Spasm. — The head is drawn back or to the right, and the
jaws are fixed. The hands are clinched and the legs extended. This
tonic contraction affects the muscles of the chest, so that respiration
is impeded and the initial pallor of the face changes to a dusky or livid
hue. The muscles of the two sides are unequally affected, so that
the head and neck are rotated or the spine is twisted. The feet are
extended and the knees and hip-joint are flexed. The arms are usually
flexed at the elbows, the hand at the wrist, and the fingers are tightly
clinched in the palm. This stage lasts only a few seconds, and then
the
(b) Clonic stage begins. The muscular contractions become inter-
mittent; at first tremulous or vibratory, they gradually become more
rapid and the limbs are jerked and tossed about violently. The mus-
cles of the face are in constant clonic spasm, the eyes roll, the eyelids
are opened and closed convulsively. The movements of the muscles
of the jaw are very forcible and strong, and it is at this time that the
tongue is apt to be caught between the teeth and lacerated. The cyan-
osis, marked at the end of the tonic stage, gradually lessens. A frothy
saliva, which may be blood-stained, escapes from the mouth. The fasces
and urine may be discharged involuntarily. The duration of this stage is
variable. It rarely lasts more than one or two minutes. The contrac-
tions become less violent and the patient gradually sinks into the con-
dition of
(c) Coma. The breathing is noisy or even stertorous, the face con-
gested, but no longer intensely cyanotic. The limbs are relaxed and the
unconsciousness is profound. After a variable time the patient can be
aroused, but if left alone he sleeps for some hours and then awakes, com-
plaining only of slight headache or mental confusion.
in some cases one attack follows the other with great rapidity and con-
sciousness is not regained. This is termed the status epileptictis, an ex-
ceptional condition, in which the patient may die of exhaustion consequent
952 DISEASES OF THE NERVOUS SYSTEM.
upon the repeated attacks. lu it the temperature is usually elevated.
After the attack the reflexes are sometimes absent ; more frequently they
are increased and the ankle clonus can usually be obtained.
The state of the urine is variable, particularly as regards the solids.
The quantity is usually increased after the attack, and albumen is not in-
frequently present.
Post-epileptic symptoms are of great importance. The patient may be
in a trance-like condition, in which he performs actions of which subse-
quently he has no recollection. More serious are the attacks of mania, in
which the patient is often dangerous and sometimes homicidal. It is held
by good authorities that an outbreak of mania may be substituted for the
fit. And, lastly, the mental condition of an epileptic patient is often seri-
ously impaired, and profound defects are common.
Paralysis, which rarely follows the epileptic fit, is usually hemiplegic
and transient.
Slight disturbances of speech also may occur ; in some instances forms
of sensory aphasia.
The attacks may occur at night, and a person may be epileptic for
years without knowing it. As Trousseau truly remarks, when a person
tells us that in the night he has incontinence of urine and awakes in the
morning with headache and mental confusion, and complains of difficulty
in speech owing to the fact that he has bitten his tongue ; if, also, there
are on the skin of the face and neck purpuric spots, the probability is very
strong indeed that he is subject to nocturnal epilepsy.
(2) Petit Mai. — This is epilepsy without the convulsions. The attack
consists of transient unconsciousness, which may come on at any time,
accompanied or unaccompanied by a feeling of faintness and vertigo.
Suddenly, for example, at the dinner table, the subject stops talking and
eating, the eyes become fixed, and the face slightly pale. Anything which
may have been in the hand is usually dropped. In a moment or two con-
sciousness is regained and the patient resumes conversation as if nothing
had happened. In other instances there is slight incoherency or the pa-
tient performs some almost automatic action. He may begin to undress
himself and on returning to consciousness find that he has partially dis-
robed. In other attacks the patient may fall without convulsive seizures.
A definite aura is rare. Though transient, unconsciousness and giddiness
are the most constant manifestations of petit mat ; there are many other
equivalent manifestations, such as sudden jerkings in the limbs, sudden
tremor, or a sudden visual sensation. Gowers mentions no less than seven-
teen different manifestations of petit mal.
After the attack the patient may be dazed for a few seconds and per-
form certain automatic actions, which may seem to be volitional. As men-
tioned, undressing is a common action, but all sorts of odd actions may be
performed, some of which are awkward or even serious. One of my pa-
tients after an attack was in the habit of tearing anything he could lay
EPILEPSY. 953
hands on, particularly books. Violent actions have been committed and
assaults made, frequently giving rise to questions which come before the
courts. This condition has been termed masked epilepsy, or epilepsia
larvata.
In a majority of the cases of petit mal convulsions finally occur, at
first slight, but ultimately the grand mal becomes well developed, and the
attacks may then alternate.
(3) Jacksonian Epilepsy. — This is also known as cortical, symptomatic,
or partial epilepsy. It is distinguished from the ordinary epilepsy by the
important fact that consciousness is retained. The attacks are usually the
result of irritative lesions in the motor zone, though there are probably
also sensory equivalents of this motor form. In a typical attack the spasm
begins in a limited muscle group of the face, arm, or leg. The zygomatic
muscles, for instance, or the thumb may twitch, or the toes may first be
moved. Prior to the twitching the patient may feel a sensation of
numbness or tingling in the part aifected. The spasm extends and may
involve the muscles of one limb only or of the face. The patient is
conscious throughout and watches, often with interest, the march of the
spasm.
The onset may be slow, and there may be time, as in a case which I
have reported, for the patient to place a pillow on the floor, so as to be
as comfortable as possible during the attack. The spasms may be local-
ized for years, but there is a great risk that the partial epilepsy may
become general. The condition is due, as a rule, to an irritative lesion
in the motor zone. Thus of 107 cases analyzed by Roland, there were
48 of tumor, 21 instances of inflammatory softening, 14 instances of
acute and chronic meningitis, and 8 cases of trauma. The remaining
instances were due to haemorrhage or abscess, or were associated with
sclerosis cerebri. Two other conditions may be mentioned, which may
cause typical Jacksonian epilepsy — namely, uraemia and progressive pa-
ralysis of the insane. A considerable number of the cases of Jackso-
nian epilepsy are found in children following hemiplegia, the so-called
post-hemiplegic epilepsy. The convulsions usually begin on the affected
side, either in the arm or leg, and the fit may be unilateral and with-
out loss of consciousness. Ultimately they become more severe and
general.
Diagnosis. — In major epilepsy the suddenness of the attack, the
abrupt loss of consciousness, the order of the tonic and clonic spasm, and
the relaxation of the sphincters at the height of the attack are distinctive
features. The convulsive seizures due to uraemia are epileptic in character
and usually readily recognized by the existence of greatly increased ten-
sion and the condition of the urine. Practically in young adults hysteria
causes the greatest difficulty, and may closely simulate true epilepsy. The
following table from Gowers's work draws clearly the chief differences
between them :
954
DISEASES OF THE NERVOUS SYSTEM.
Apparent cause
Warning
Onset
Scream
Convulsion
Biting
Micturition
Defecation
Talking
Duration
Restraint necessary.
Termination
Epileptic.
none.
any, but cs^pecially unilat-
eral or epigastric aurae.
always sudden.
at onset.
rigidity followed by "jerk-
ing," rarely rigidity alone.
tongue.
frequent.
occasional.
never.
a few minutes.
to prevent accident,
spontaneous.
Hysteroid.
emotion.
palpitation, malaise, choking, bi-
lateral foot aura.
often gradual.
during course.
rigidity or "struggling," throwing
about of iimbs or head, arching
of back.
lips, hands, or other people and
things.
never.
never.
frequent.
more than ten minutes, often much
longer.
to control violence.
spontaneous or induced (water,
etc.).
Kecurring epileptic seizures in a person over thirty who has not had
previous attacks is always suggestive of organic disease. According to H.
C. Wood, whose opinion is supported by that of Fournier, in nine cases
out of ten the condition is due to syphilis.
Petit mat must be distinguished from attacks of syncope, and the ver-
tigo of Meniere's disease, of a cardiac lesion, and of indigestion. In these
cases there is no actual loss of consciousness, which forms a characteristic
though not an invariable feature of petit mal.
Jackson ian epilepsy has features so distinctive and peculiar that it is
at once recognized. It is by no means easy, however, always to deter-
mine upon what the spasm depends. Irritation in the motor centres
may be due to a great variety of causes, among which tumors and local-
ized meningo-encephalitis are the most frequent; but it must not be
forgotten that in uraemia localized epilepsy may occur. The most typi-
cal Jacksonian spasms also are not infrequent in general paresis of the
insane.
Prognosis. — This may be given to-day in the words of Hippocrates:
" The prognosis in epilepsy is unfavorable when the disease is congenital,
and when it endures to manhood, and when it occurs in a grown person
without any previous cause. . . . The cure may be attempted in young
persons, but not in old."
Death during the fit rarely occurs, but it may happen if the patient
falls into the water or if the fit comes on while he is eating. Occasionally
the fits seem to stop spontaneously. This is particularly the case in the
epilepsy in children which has followed the convulsions of teething or of
the fevers. Frequency of the attacks and marked mental disturbance are
unfavorable indications. Hereditary predisposition is apparently of no
moment in tlie prognosis. Tlie outlook is better in males than in females.
The post-hemiplegic epilepsy is rarely arrested. Of the cases coming on
EriLEPSY. 955
in adults, those due to syphilis and to local affections of the brain allow a
more favorable prognosis.
Treatment. — General. — In the case of children the parents should
be made to understand from the outset that epilepsy in the great majority of
cases is an incurable affection, so that the disease may interfere as little as
possible with the education of the child. The subjects need firm but kind
treatment. Indulgence and yielding to caprices and whims are followed
by weakening of the moral control, which is so necessary in these cases.
The disease does not incapacitate a person for all occupation. It is much
better for epileptics to have some definite pursuit. There are many
instances in which they have been persons of extraordinary mental and
bodily vigor ; as, for example, Julius Caesar and Kapoleon. One of the
most distressing features in epilepsy is the gradual mental impairment
which follows in a certain number of cases. If such patients become ex-
tremely irritable or show signs of violence they should be placed under
supervision in an asylum. Marriage should be forbidden to epileptics.
During the attack a cork or bit of rubber should be placed between the
teeth and the clothes should be loosened. The patient should be in the
recumbent posture. As the attack usually passes off with rapidity, no
special treatment is necessary, but in cases in which the convulsion is pro-
longed a few whiffs of chloroform or nitrite of amyl or a h}^odermic of
a quarter of a grain of morphia may be given.
Dietetic. — The old authors laid great stress upon regimen in epilepsy.
The important point is to give the patient a light diet at fixed hours,
and on no account to permit overloading of the stomach. Meat should
not be given more than once a day. There are cases in which animal
food seems injurious. A strictly vegetable diet has been warmly recom-
mended. The patient should not go to sleep until the completion of
gastric digestion.
Medicinal. — The bromides are the only remedies which have a special
influence upon the disease. Either the sodium or potassium salt may be
given. Sodium bromide is probably less irritating and is better borne for
a long period. It may be given in milk, in wiiich it is scarcely tasted.
In all instances the dilution should be considerable. In adults it is well
taken in soda water or in some mineral water. The dose for an adult
should be from half a drachm to a drachm and a half daily. As Seguin
recommends, it is often best to give but a single dose daily, about four to
six hours before the attacks are most likely to occur. For instance, in
the case of nocturnal epilepsy a drachm should be given an hour or two
after the evening meal. If the attack occurs early in the morning, the
patient should take a full dose when he awakes. When given three times
a day it is best given after meals. Each case should be carefully studied to
determine how much bromide should be used. The individual suscepti-
bility varies and some patients require more than others. Fortunately,
children take the drug well and stand proportionately larger doses than
956 DISEASES OF THE NERVOUS SYSTExM.
adults. Saturation is indicated by certain unpleasant effects, particu-
larly drowsiness, mental torpor, and gastric and cardiac distress. Loss of
palate reflex is one of the earliest indications that the system is under the
influence of the bromides, and is a condition which should be attained. A
very unpleasant feature is the development of acne, which, however, is no
indication of bromism. Seguin states that the tendency to this is much
diminished by giving the drug largely diluted in alkaline waters and ad-
ministering from time to time full doses of arsenic. To be effectual the
treatment should be continued for a prolonged period and the cases
should be incessantly watched in order to prevent bromism. The medi-
cine should be continued for at least two years after the cessation of the
fits ; indeed, Seguin recommends that the reduction of the bromides should
not be begun until the patient has been three years without any mani-
festations. Written directions should be given to the mother or to the
friends of the patient, and he should not himself be held responsible for
the administration of the medicine. A book should be provided in which
the daily number of attacks and the amount of medicine taken should be
noted.
Among other remedies which have been recommended as controlling
epilepsy are chloral, cannabis indica, zinc, nitroglycerin, and borax. Nitro-
glycerin is sometimes advantageous in 2^etit mal, but is not of much serv-
ice in the major form. To be beneficial it must be given in full doses,
from two to five minims of the one per cent solution, and increased
until the physiological effects are produced. Counter-irritation is rarely
advisable. When the aura is very definite and constant in its onset, as
from the hand or from the toe, a blister about the part or a ligature
tightly applied may stop the oncoming fit. In children, care should be
taken that there is no source of peripheral irritation. In boys, adherent
prepuce may occasionally be the cause. The irritation of teething, the
presence of worms, and foreign bodies in the ears or nose have been asso-
ciated with epileptic seizures.
The subjects of a chronic and, in most cases, a hopelessly incurable
disease, epileptic patients form no small portion of the unfortunate victims
of charlatans and quacks, who prescribe to-day, as in the time of the father
of medicine, " purifications and spells and other illiberal practices of like
kind."
Surgical. — In Jacksonian epilepsy the propriety of surgical inter-
ference is universally granted. It is questionable, however, whether in the
epilepsy following hemiplegia, considering the anatomical condition, it is
likely to be of any benefit. In idiopathic epilepsy, when the fit starts in
a certain region — the thumb, for instance — and the signal symptom is in-
variable, the centre controlling this part may be removed. This procedure
has been practised by Macewen, Ilorsley, Keen, and others, but time alone
can determine its value. The traumatic epilepsy, in which the fit follows
fracture, is much more hopeful.
MIGRAINE. 957
The operation, ^;^r se^ appears in seme cases to have a curative effect.
Thus of 50 cases of trephining for epilepsy in which nothing abnormal was
found to account for the symptoms, 25 were reported as cured and 18 as im-
proved.* The operations have not been always on the skull, and White
has collected an interesting series in which various surgical procedures
have been resorted to, often with curative effect, such as ligation of the
carotid artery, castration, tracheotomy, excision of the superior cervical
ganglia, incision of the scalp, circumcision, etc.
VII. MIGRAINE {Hemicrania; Sick Headache).
Definition. — A paroxysmal affection characterized by severe head-
ache, usually unilateral, and often associated with disorders of vision.
Etiology. — The disease is frequently hereditary and has occurred
through several generations. Women and the members of neurotic fami-
lies are most frequently attacked. It is an affection from which many dis-
tinguished men have suffered and have left on record an account of the dis-
ease, notably the astronomer Airy. Edward Liveing's work is the standard
authority upon which most of the subsequent articles have been based. A
gouty or rheumatic taint is present in many instances. Sinkler has called
special attention to the frequency of reflex causes. Migraine has long been
known to be associated with uterine and menstrual disorders. Many of
the headaches from eye-strain are of the hemicranial type. Brunton refers
to caries of the teeth as a cause of these headaches, even when not associ-
ated with toothache. Cases have been described in connection with ade-
noid growths in the pharynx, and particularly with abnormal conditions
of the nose. Many of the attacks of severe headaches in children are of
this nature, and the eyes and nostrils should be examined with great care.
Sinkler refers to a case in a child of two years, and Gowers states that a
third of all the cases begin between the fifth and tenth years of age. The
direct influences inducing the attack are very varied. Powerful emotions
of all sorts are the most potent. Mental or bodily fatigue, digestive dis-
turbances, or the eating of some particular article of food may be followed
by the headache. The paroxysmal character is one of the most striking
features, and the attacks may recur on the same day every week, every
fortnight, or every month.
Symptoms. — Premonitory signs are present in many cases, and the
patient can tell when an attack is coming on. Remarkable prodromata
have been described, particularly in connection with vision. Apparitions
may appear — visions of animals, such as mice, dogs, etc. Transient he-
mianopia or scotoma may be present. In other instances there is spas-
mo<lic action of the pupil on the affected side, which dilates and contracts
* J. William White, Curative Effects of Operations ^er se, Annals of Surgery, 1891.
958 DISEASES OP THE NERVOUS SYSTEM.
iilternately, the condition known as liippus. Frequently the disturbance
of vision is only a blurring, or there are balls of light, or zigzag lines, or
tlie so-called fortification spectra (teichopsia), which may be illuminated
with gorgeous colors. Disturbances of the other senses are rare. Xumb-
ness of the tongue and face and occasionally of the hand may occur with
tingling. More rarely there are cramps or spasms in the muscles of the
affected side. Transient aphasia has also been noted. Some patients
show marked psychical disturbance, either excitement or, more commonly,
mental confusion or great depression. Dizziness occurs in some cases.
The headache follows a short time after the prodromal symptoms have
appeared. It is cumulative and expansile in character, beginning as a
localized small spot, which is generally constant either on the temple or
forehead or in the eyeball. It is usually described as of a penetrating,
sharp, boring character. At first unilateral, it gradually spreads and in-
volves the side of the head, sometimes the neck, and the pains may pass
into the arm. In other cases both sides are affected. Nausea and vomit-
ing are common symptoms. If the attack comes on when the stomach is
full, vomiting usually gives relief. Vaso-motor symptoms may be pres-
ent. The face, for instance, may be pale, and there may be a marked
difference between the two sides. Subsequently the face and ear on the
affected side may become a burning red from the vaso-dilator influences.
The pulse may be slow. The temporal artery on the affected side may be
firm and hard, and in a condition of arterio-sclerosis — a fact which has
been confirmed anatomically by Thoma. Few affections are more pros-
trating than migraine, and during the paroxysm the patient may scarcely
be able to raise the head from the pillow. The slightest noise or light
aggravates the condition.
The duration of the entire attack is variable. Tlie severer forms usually
incapacitate the person for at least three days. In other instances the en-
tire attack is over in a day. The disease recurs for years, and in cases with
a marked hereditary tendency may persist throughout life. In women the
attacks often cease after the climacteric, and in men after the age of fifty.
Two of the greatest sufferers I have known, who had recurring attacks
every few weeks from early boyhood, now have complete freedom.
The nature of the disease is unknown. Liveing's view, that it is a
nerve storm or form of periodic discharge from certain sensory centres and
is related to epilepsy, has found much favor. According to this view, it
is the sensory equivalent of a true epileptic attack. Mollendorf, Latham,
and others regard it as a vaso-motor neurosis, and hold that the early
symptoms arc due to vaso-constrictor and the later symptoms to vaso-dila-
tor influences. The fact of the development of arterio-sclerosis in the
arteries of the affected side is a point of interest bearing upon this view.
Treatment. — The patient is fully aware of the causes which precipi-
tate an attack. Avoidance of excitement, regularity in the meals, and
moderation in diet are important rules. The treatment should be directed
NEURALGIA. 959
toward the removal of the conditions upon which the attacks depend. In
children much may be done by watchfulness and care on the part of the
mother in regulating the bowels and watching the diet of the child.
Errors of refraction should be adjusted. On no account should such chil-
dren be allowed to compete in school for prizes. A prolonged course of
bromides sometimes proves successful. If anaemia is present, iron and
arsenic should be given. AYhen the arterial tension is increased a course
of nitroglycerin may be tried. Not too much, however, should be expect-
ed of the preventive treatment of migraine. It must be confessed that in
a very large proportion of the cases the headaches recur in spite of all we
can do. During the paroxysm the patient should be kept in bed and ab-
solutely quiet. If the patient feels faint and nauseated, a small cup of
hot, strong coffee or twenty drops of chloroform give relief. Cannabis
indica is probably the most satisfactory remedy. Seguin recommends a
prolonged course of the drug. Antipyrin, antifebrin, and phenacetin
have been much used of late. When given early, at the very outset of the
paroxysm, they are sometimes effective. The doses which have been rec-
ommended of antifebrin and antipyrin are often dangerous, and I have
seen in a case of migraine unpleasant collapse symptoms follow a twenty-
five-grain dose of antipyrin which the patient had taken on her own re-
sponsibility. Smaller, repeated doses are more satisfactory. Of other
remedies, caffeine, in five-grain doses of the citrate, nux vomica, and ergot
have been recommended. Electricity does not appear to be of much
service.
VIII. NEURALGIA.
Definition. — A painful affection of the nerves, due either to func-
tional disturbance of their central or peripheral extremities or to neuritis
in their course.
Etiology. — Members of neuropathic families are most subject to the
disease. It affects women more than men. Children are rarely attacked.
Of all causes, debility is the most frequent. It is often the first indication
of an enfeebled nervous system. The various forms of anaemia are fre-
quently associated with neuralgia. It may be a prominent feature at tlie
onset of certain acute diseases, particularly typhoid fever. Malaria is be-
lieved to be a potent cause, but it has not been shown that neuralgia is
more frequent in malarial districts, and the error has probably arisen from
regarding periodicity as a special manifestation of paludism. It occasion-
ally occurs in malarial cachexia. Exposure to cold is a cause in very sus-
ceptible persons. Reflex irritation, particularly from carious teeth, may in-
duce neuralgia of the fifth nerve. The disease occurs sometimes in
rheumatism, gout, lead poisoning, and diabetes.
Symptoms. — Before the onset of the pain there may be uneasy sen-
sations, sometimes tingling in the part which will be affected. The pain
000 DISEASES OF THE NERVOUS SYSTEM.
is localized to a certain group or division of nerves, usually affecting one
side. The pain is not constant, but paroxysmal, and is described as stab-
bing, burning, or darting in character. The skin may be exquisitely ten-
der in the affected region, particularly in certain points along the course
of the nerve, the so-called tender points. Movements, as a rule, are pain-
ful. Trophic and vaso-motor changes may accompany the paroxysm ; the
skin may be cool, and subsequently hot and burning, occasionally local
cedema or erythema occurs. More remarkable still are the changes in the
hair, which may become blanched (canities), or even fall out. Fortunate-
ly, such alterations are rare. Twitchings of the muscles, or even spasms,
may be present during the paroxysm. After lasting a variable time — from
a few minutes to many hours — the attack subsides. Recurrence may be
at definite intervals — every day at the same hour, or at intervals of two,
three, or even seven days. Occasionally the paroxysms develop only at
the catamenia. This periodicity is quite as marked in non-malarial as in
malarial regions.
Clinical Varieties, depending on the Nerve Groups affected.— (1) Tri-
facial Neuralgia ; Tic Douloureux ; Prosopalgia. — All the branches are
rarely involved together. The ophthalmic is most often affected, but in
severe attacks the pains, though more intense in one division, radiate over
the other branches. At the outset there may be hyperaesthesia of the skin
and sensitiveness of the mucous membrane. Pressure is painful at the
points of emergence of the nerve trunk, and where the nerves enter the
muscles. Sometimes in addition, as Trousseau pointed out, there are
pains at the occipital protuberance and in the upper cervical spines.
When the ophthalmic division is affected the eye may weep and the con-
junctivae are injected and painful. In the upper maxillary division there
is a tender point where the nerve leaves the infraorbital canal, and the
pain is specially marked along the upper teeth. In the lower branches,
which are more frequently involved, there are painful points along the
auriculo-temporal nerve and the pain radiates in the region of the ear
along the lower jaw and teeth. The movements of mastication and speak-
ing may be painful. Salivation is not uncommon. Herpes may occur
about the eye or the lips. In protracted cases there may be atrophy or
induration of the skin. Some of the forms of facial neuralgia are of
frightful intensity and the recurring attacks render the patient's life
almost insupportable.
(2) Cervico-occijntal neuralgia involves the posterior branches of the
first four cervical nerves, particularly the inferior occipital, at the emer-
gence of which there is a painful point about half-way between the mastoid
process and the first cervical vertebra. It may be caused by cold, and
these nerves are often affected in cervical caries.
(3) Cervico-hrachial neuralgia involves the sensory nerves of the
brachial plexus, particularly in the cubital division. When the circumflex
nerve is involved the pain is in the deltoid. The pain is most commonly
NEURALGIA. 9G1
about the shoulder and down the course of the ulnar nerve. . There is
usually a marked tender point upon this nerve at the elbow. This form
rarely follows cold, but more frequently results from rheumatic affections
of the joints, and trauma.
(4) Neuralgia of the ijhrenic nerve is rare. It is sometimes found in
pleurisy and in pericarditis. The pain is chiefly at the lower part of the
thorax on a line with the insertion of the diaphragm, and here may be
painful points on deep pressure. Full inspiration is painful, and there is
great sensitiveness on coughing or in the performance of any movement
by which the diaphragm is suddenly depressed.
(5) Intercostal Neuralgia. — Next to the tic douloureux this is the
most important form. It is most frequent in women and very common
in hysteria and anaemia. The pain in caries and aneurism is felt in the in-
tercostal nerves. They are also the seat of the intense pain in inflammation
of the pleura. The pain is often constant and exaggerated by movements.
Pleurodynia is supposed by some to be local intercostal neuralgia, con-
fined to one spot, usually along the course or at the exit of the nerves.
Herpes zoster or zona occurs with the most aggravated form of intercostal
neuralgia. The pain usually precedes the erujDtion, which consists of a
series of pearly vesicles, which take two or three days to develop and
gradually disappear. The eruption may occur without much pain. The
most distressing feature in the complaint is the persistence in the pain
after the eruption has subsided. The eruption and the neuralgia are in
reality manifestations of neuritis. Changes have been found in the nerves
and in the ganglia of the posterior roots. The pain of zona may persist
indefinitely, and it has been known to be so intractable that in despair the
person has committed suicide.
(6) Lumbar Neuralgia. — The affected nerves are the posterior fibres
of the lumbar plexus, particularly the ilio-scrotal branch. The pain is in
the region of the iliac crest, along the inguinal canal, in the spermatic
cord, and in the scrotum or labium majus. The affection known as irri-
table testis, probably a neuralgia of this nerve, may be very severe and
accompanied by syncopal sensations.
(7) Coccydynia. — This is regarded as a neuralgia of the coccygeal
plexus. It is most common in women, and is aggravated by the sitting
posture. It is very intractable, and may necessitate the removal of the
coccyx, an operation, however, which is not always successful. Neuralgias
of the nerves of the leg have already been considered.
(8) Neuralgias of the Nerves of the Feet.
Painful Heel. — Both in women and men there may be about the heel
severe pains which interfere seriously with walking — the pododynia of
S. I). Gross. There may be little or no swelling, no discoloration, and no
affection of the joints. The pain is usually most severe over the heel ;
sometimes in a very limited spot, sometimes in the line of the metatarso-
phalangeal joint. Probably this painful affection depends upon many
9G2 DISEASES OF THE NERVOUS SYSTEM.
different conditions. It may be associated with rheumatism or gout, and
with certain occupations — persons who have to stand for a long time on
tlieir feet. In other instances it occurs with flat-foot.
Plantar Xeuralgia. — Tliis is often associated with a definite neuritis,
such as follows typhoid fever, and has been seen in an aggravated form
in caisson disease (Hughes). The pain may be limited to the tips of the
toes or to the ball of the great toe. Numbness, tingling, and hyper-
aesthesia or sweating may occur with it. Following the cold-bath treat-
ment in typhoid fever it is not uncommon for patients to complain of
great sensitiveness in the toes.
Erythromelalgia. — Under this term Weir Mitchell described a con-
dition which is associated with great pain in the heel or in the sole of the
foot, with vascular changes, either an acute hypersemia or cyanosis. Some
of the cases should unquestionably be regarded as Eaynaud's disease.
(9) Visceral Neuralgias. — The more important of these have already
been referred to in connection with the cardiac and the gastric neuroses.
They are most frequent in women, and are constant accompaniments of
neurasthenia and hysteria. The pains are most common in the pelvic
region, particularly about the ovaries. ISTephralgia is of great interest, for,
as has already been mentioned, the symptoms may closely simulate those
of stone.
Treatment. — Causes of reflex irritation should be carefully removed.
The neuralgia, as a rule, recurs unless the general health improves; so
that tonic and hygienic measures of all sorts should be employed. Often
a change of air or surroundings will relieve a severe neuralgia. I have
known obstinate cases to be cured by a prolonged residence in the mount-
ains, with an out-of-door life and plenty of exercise. Of general remedies,
iron is often a specific in the cases associated with chlorosis and angemia.
Arsenic, too, is very beneficial in these forms, and should be given in
ascending doses. The value of quinine has been much overrated. It prob-
ably has no more influence than any other bitter tonic, except in the rare
instances in which the neuralgia is definitely associated with malarial poi-
soning. Strychnine, cod-liver oil, and phosphorus are also advantageous.
Of remedies for the pain, the new analgesics should first be tried — anti-
pyrin, antifebrin, and phenacetin — for they are sometimes of service.
Morphia should be given with great caution, and only after other reme-
dies have been tried in vain. On no consideration should the patient be
allowed to use the hypodermic syringe. Gelsemium is highly recom-
mended. Of nervine stimulants, valerian and ether, which often act well
together, may be given. Alcohol is a valuable, though dangerous, remedy,
and shoukl not be ordered for women. In the trifacial neuralgia nitro-
glycerin in large doses may be tried. Aconitia in doses of from one two-
hundredth to one one-hundred-and-fiftieth of a grain may be tried. In
gouty and rheumatic subjects cannabis indica and cimicifuga are recom-
mended with the lithium salts.
PROFESSIONAL SPASMS; OCCUPATION NEUROSES. 903
Of local applications, the thermo-cautcry is invaluable, particularly in
zona and the more chronic forms of neuralgia. Acupuncture may be
used, or aquapuncture, the injection of distilled water beneath the skin.
Chloroform liniment, camphor and chloral, menthol, the oleates of mor-
phia, atropia, and belladonna used with lanolin may be tried. Freezing
over the tender point with ether spray is sometimes successful. The con-
tinuous current may be used. The sponges should be warm, and the posi-
tive pole should be placed near the seat of the pain. The strength of the
current should be such as to cause a slight tingling or burning, but not
pain.
The surgical treatment of intractable neuralgia embraces nerve stretch-
ing and excision. The latter is the most satisfactory, but too often the
pain returns.
IX. PROFESSIONAL SPASMS; OCCUPATION NEUROSES.
The continuous and excessive use of the muscles in performing a certain
movement may be followed by an irregular, involuntary spasm or cramp,
which may completely check the performance of the action. The condi-
tion is found most frequently in writers, hence the term writer's cramp
or scrivener's palsy ; but it is also common in piano and violin players and
in telegraph operators. The spasms occur in many other persons, such as
milkmaids, weavers, and cigarette-rollers.
The most common form is writer's cramp, which is much more fre-
quent in men than in women. Of 75 cases of impaired writing power re-
ported by Poore, all of the instances of undoubted writer's cramp were in
men. Morris J. Lewis states that in this country, in the telegrapher's
cramp, women, who are employed a great deal in telegraphy, are much
less frequently affected (only 4 out of 43 cases). Persons of a nervous
temperament are more liable to the disease. Occasionally it follows slight
injury.
Gowers states that in a majority of the cases a faulty method of writing
has been employed, using either the little finger or the wrist as the fixed
point. Persons who write from the middle of the forearm or from the
elbow are rarely affected.
No anatomical changes have been found. The most reasonable ex-
planation of the disease is that it results from a deranged action of the
nerve centres presiding over the muscular movements involved in the act
of writing, a condition which has been termed irritable weakness. " The
education of centres which may be widely separated from each other for
the performance of any delicate movement is mainly accomplished by less-
ening the lines of resistance between them, so that the movement, which
was at first produced by a considerable mental effort, is at last executed
almost unconsciously. If, therefore, through prolonged excitation, this
61
964: DISEASES OF THE NERVOUS SYSTEM.
lessened resistance be carried too far, there is an increase and irregular
discharge of nerve energy, which gives rise to spasm and disordered move-
ment. According to this view, the muscular weakness is explained by an
impairment of nutrition accompanying that of function, and the dimin-
ished faradic excitability by the nutritional disturbance descending the
motor nerves." (Gay.)
Symptoms. — These may be described under five heads (Lewis).
(a) Cramp or Spasm. — This is often an early symptom and most com-
monly affects the forefinger and thumb ; or there may be a combined move-
ment of flexion and adduction of the thumb, so that the pen may be twisted
from the grasp and thrown to some distance. Weir Mitchell has described
a lock-spasm, in which the fingers become so firmly contracted upon the
pen that it cannot be removed.
{h) Paresis and Paralysis. — This may occur with the spasm or alone.
The patient feels a sense of weakness and debility in the muscles of the
hand and arm and holds the pen feebly. Yet in these circumstances the
grasp of the hand may be strong and there may be no paralysis for ordi-
nary acts.
(c) Tremor. — This is most commonly seen in the forefinger and may
be a premonitory symptom of atrophy. It is not an important symptom,
and is rarely sufficient to produce disability.
{d) Pain. — Abnormal sensations, particularly a tired feeling in the
muscles, are very constantly present. Actual pain is rare, but there may
be irregular shooting pains in the arm. Numbness or soreness may exist.
If, as sometimes happens, a subacute neuritis develops, there may be pain
over the nerves and numbness or tingling in the fingers.
(e) Vasomotor Disturbances. — These may occur in severe cases. There
may be hyperaesthesia. Occasionally the skin becomes glossy, or there is
a condition of local asphyxia resembling chilblains. In attempting to
write, the hand and arm may become flushed and hot and the veins increased
in size. Early in the disease the electrical reactions are normal, but in ad-
vanced cases there may be diminution of faradic and sometimes increase
in the galvanic irritability.
Diagnosis. — A well-marked case of writer's cramp or palsy could
scarcely be mistaken for any other affection. Care must be taken to ex-
clude the existence of any cerebro-spinal disease, such as progressive mus-
cular atrophy or hemiplegia. The physician is sometimes consulted by
nervous persons who fancy they are becoming subject to the disease and
complain of stiffness or weakness without displaying any characteristic
features.
Prognosis. — The course of the disease is usually chronic. If taken
in time and if the hand is allowed perfect rest, the condition may im-
prove rapidly, but too often there is a strong tendency to recurrence. The
patient may learn to write with the left hand, but this also may after a
time be attacked.
TETANY. 965
Treatment. — Various prophylactic measures have been advised. As
mentioned, it is important that a proper method of writing be adopted.
Gowers suggests that if all persons wrote from the shoulder writer's cramp
would practically not occur. Various devices have been invented for re-
lieving the fatigue, but none of them are very satisfactory. The use of the
type-writer has diminished very much the frequency of scrivener's palsy.
Eest is essential. No measures are of value without this. Massage and
manipulation, when combined with systematic gymnastics, give the best
results. Poore recommends the galvanic current applied to the muscles,
which are at the same time rhythmically exercised.
The nutrition of the patients is apt to be much impaired, and cod-liver
oil, strychnia, and other tonics will be found advantageous. Local appli-
cations are of little benefit. Tenotomy and nerve-stretching have been
abandoned.
X. TETANY.
Definition. — An affection characterized by peculiar tonic spasms,
either paroxysmal or continued, of the extremities.
Etiology. — The disease occurs under very different conditions. Four
varieties may be recognized.
(a) Epidemic tetany, also known as rheumatic tetany. In certain
parts of the continent of Europe the disease has prevailed widely, particu-
larly in the winter season. Von Jaksch, who has described an epidemic
form occurring in young men of the working classes, sometimes with
slight fever, regards the disease as infectious. This form is acute, lasting
only two or three weeks and rarely proving fatal.
(b) A majority of the cases are found in association with debility fol-
lowing lactation and chronic diarrhoea, or in the malnutrition of rickets.
From its occurrence in nursing women Trousseau called it nurse's con-
tracture. It may also occur during pregnancy. It has been found as a
sequence of the acute fevers, and in some typhoid epidemics many cases
have occurred.
(c) Tetany may follow removal of the thyroid gland. Thirteen cases,
for example, followed seventy-eight operations on enlarged thyroid in Bill-
roth's clinic, and six of them proved fatal. James Stewart has reported
an instance in which with the tetany there were symptoms of myxoedema,
and no trace of the thyroid gland. Eemoval of the thyroid in dogs has
also been followed by tetany.
(d) And, lastly, there is a form of fatal tetany which is associated
with dilatation of the stomach, particularly after the organ has been
washed out. A case has been reported in this country by F. T. Miles.
On this continent tetany is an extremely rare disease. In the discus-
siori on Stewart's case at the Association of American Physicians, Wash-
ington, 1880, Weir Mitchell stated that he had seen but two instances in
966 DISEASES OF THE NERVOUS SYSTEM.
his long and varied experience, while Pepper had seen but one case, and
that was in a child.
The nature of the disease is unknown, but it probably depends upon
the action of some toxic agent on the motor-nerve cells.
Symptoms. — In cases associated with general debility or in children
with rickets the spasm is limited to the hands and feet. The fingers are
bent at the metacarpo-phalangeal joint, extended at the terminal joints,
pressed close together, and the thumb is contracted in the palm of the
hand. The wrist is flexed, the elbows are bent, and the arms are folded
over the chest. In the lower limbs the feet are extended and the toes ad-
ducted. The muscles of the face and neck are less commonly involved,
but in severe cases there may be trismus, and the angles of the mouth are
drawn out. The skin of the hands and feet is sometimes tense and cede-
matous. The spasms are usually paroxysmal and last for a variable time.
In children the attack may pass off in a few hours. In some of the
severer chronic cases in adults the stiffness and contracture may continue
or even increase for many days, and the attack may last as long as two
weeks. In the acute cases the temperature may be elevated and the pulse
quickened. In the severe paroxysms there may be involvement of the
muscles of the back and of the thorax, inducing dyspnoea and cyanosis.
Two additional features, valuable in diagnosis, are present. The irritabil-
ity of the nerves is enormously increased both during the period of tetany
and subsequently. Thus a minimal strength of current necessar}^ to pro-
duce a contracture during the quiescent period is sufficient during the
attack to cause a distinct tetanic contraction. The second point is the
so-called Trousseau's phenomenon : pressure on the larger arteries, some-
times on the nerve trunk, will excite the spasm, which continues while the
pressure is kept up.
Diagnosis. — The disease is readily recognized. It is a mistake to
call instances of carpo-pedal spasm of children true tetany. It is com-
mon to find in rickety children or in cases of severe gastro-intestinal
catarrh a transient spasm of the fingers or even of the arms. By many
authors these are considered cases of mild tetany, and there are all grades
in rickety children between the simple carpo-pedal spasm and the con-
dition in which the four extremities are involved ; but it is well, I think,
to limit the term tetany to the severer affection.
With true tetanus the disease is scarcely ever confounded, as the com-
mencement of the spasm in the extremities, the attitude of the hands,
and the etiological factors are very different. Hysterical contractures are
usually unilateral.
Except in the cases associated with dilated stomach and those which
follow thyroidectomy the prospect of recovery is good.
Treatment. — In the case of children the condition with which the
tetany is associated should be treated. Baths and cold sponging are rec-
ommended and often relieve the spasm as promptly as in child-crowing.
(
HYSTERIA. 9G7
Bromide of potassium may be tried. In severe cases chloroform inhala-
tions may be given. Massage, electricity, and the spinal ice-bag have also
been used with success. Cases, however, may resist all treatment, and the
spasms recur for many years.
XI. HYSTERIA.
Definition. — A state in which ideas control the body and produce
morbid changes in its functions (Mobius).
Etiology. — The affection is most common in women, and usually ap-
pears first about the time of puberty, but the manifestations may continue
until the menopause, or even until old age. Men and boys, however, are
by no means exempt, and of late years hysteria in the male has attracted
much attention. It occurs in all races, but is much more prevalent, par-
ticularly in its severer forms, in members of the Latin race. In this
country the milder grades are common, but the graver forms are rare in
comparison with the frequency with which they are seen in France.
Of predisposing causes, two are important — heredity and education.
The former acts by endowing the child with a mobile, abnormally sensi-
tive nervous organization. We see cases most frequently in families with
marked neuropathic tendencies, the members of which have suffered from
neuroses of various sorts. Education at home too often fails to inculcate
habits of self-control. A child grows to girlhood with an entirely errone-
ous idea of her relations to others, and accustomed to have every whim
gratified and abundant sympathy lavished on every woe, however trifling,
she reaches womanhood with a moral organization unfitted to withstand
the cares and worries of every-day life. At school, between the ages of
twelve and fifteen, the most important period in her life, when the vital
energies are absorbed in the rapid development of the body, she is often
cramming for examinations and cooped in close school-rooms for six or
eight hours daily. The result too frequently is an active, bright mind in
an enfeebled body, ill adapted to subserve the functions for which it was
framed, easily disordered, and prone to react abnormally to the ordinary
stimuli of life. Among the more direct influences are emotions of various
kinds, fright occasionally, more frequently love affairs, grief, and domestic
worries. Physical causes less often bring on hysterical outbreaks, but they
may follow directly upon an injury or develop during the convalescence
from an acute illness or be associated with disease of the generative organs.
The name hynteria indicates how important was believed to be the part
played by the uterus in the causation of the disease. Opinions differ a
good deal on this question, but undoubtedly in many cases there are ova-
rian and uterine disorders the rectification of which sometimes cures the
disease. Sexual excess, particularly masturbation, is an important factor,
both in girls and boys.
968 DISEASES OF THE NERVOUS SYSTEM.
Symptoms. — A useful division is into the convulsive and non-con-
vulsive varieties.
Convulsive Hysteria. — {a) Minor Forms. — The attack most commonly
follows emotional disturbance. It may set in suddenly or be preceded by
symptoms, called by the laity " hysterical," such as laughing and crying
alternately, or a sensation of constriction in the neck, or of a ball rising in
the throat — the globus hystericus. Sometimes, preceding the convulsive
movements, there may be painful sensations arising from the pelvic, ab-
dominal, or thoracic regions. From the description these sensations
resemble aur^. They become more intense with the rising sensation of
choking in the neck and difficulty in getting breath, and the patient falls
into a more or less violent convulsion. It will be noticed that the fall is
not sudden, as in epilepsy, but the subject falls, as a rule, easily, often
picking a soft spot, like a sofa or an easy chair, and in the movements
apparently exercises care to do herself no injury. Yet at the same time
she appears to be quite unconscious. The movements are clonic and
disorderly, consisting of to-and-fro motion of the trunk or pelvic mus-
cles, and the head and arms are thrown about in an irregular manner.
The paroxysm after a few minutes slowly subsides, then the patient
becomes emotional, and gradually regains consciousness. When ques-
tioned the patient may confess to having some knowledge of the events
which have taken place, but, as a rule, has no accurate recollection. Dur-
ing the attack the abdomen may be much distended with flatus, and sub-
sequently a large amount of clear urine may be passed. These attacks
vary greatly in character. There may be scarcely any movements of the
limbs, but after a nerve storm the patient sinks into a torpid, semi-uncon-
scious condition, from which she is roused with great difficulty. In some
cases from this state the patient passes into a condition of catalepsy.
(b) Major Forms ; Hystero-epilejjsy. — This condition has been specially
studied by Charcot and his pupils. Typical instances passing through the
various phases are very rare in this country. The attack is initiated by
certain prodromata, chiefly minor hysterical manifestations, either foolish
or unseemly behavior, excitement, sometimes dyspeptic symptoms with
tympanites, or frequent micturition. Areas of hyperaesthesia may at this
time be marked, the so-called hysterogenic spots so elaborately described
by Richet. These are usually symmetrical and situated over the upper
dorsal vertebra, and in front in a series of symmetrically placed spots on
the chest and abdomen, the most marked being those in the inguinal
regions over the ovaries. Painful sensations or a feeling of oppression
and a globus rising in the throat may be complained of prior to the onset
of the convulsion, which, according to French writers, has four distinct
stages : (1) Epileptoid condition, which closely simulates a true epileptic
attack with tonic spasm (often leading to opisthotonos), grinding of the
teeth, congestion of the face, followed by clonic convulsions, gradual
relaxation, and coma. This attack lasts rather longer than a true epi-
HYSTERIA. 900
leptic attack. (2) Succeeding this is a period which Charcot has termed
cloiunism^ in which there is an emotional display and a remarkable series
of contortions or of cataleptic poses. (3) Then in typical cases there is
a stage in which the patient assumes certain attitudes expressive of the
various passions — ecstasy, fear, beatitude, or erotism. (4) Finally con-
sciousness returns and the patient enters upon a stage in which she may
display very varied symptoms, chiefly manifestations of a delirium with
the most extraordinary hallucinations. Visions are seen, voices heard,
and conversations held with imaginary persons. In this stage patients
will relate with the utmost solemnity imaginary events, and make ex-
traordinary and serious charges against individuals. This sometimes gives
a grave aspect to these seizures, for not only will the patient at this stage
make and believe the statements, but when recovery is complete the hal-
lucination sometimes persists. We seldom see in this country attacks
having this orderly sequence. Much more commonly the convulsions
succeed each other at intervals for several days in succession. Here is a
striking difference between hystero-epilepsy and true epilepsy. In the
latter the status epilepticus, if persistent, is always serious, associated
with fever, and frequently fatal, while in hystero-epilepsy attacks may
recur for days without special danger to life. After an attack of hystero-
epilepsy the patient may sink into a state of trance or lethargy, in which
she may remain for days.
Non-convulsive Forms. — So complex and varied is the clinical picture
of hysteria that various manifestations are best considered according to
the systems which are involved.
(1) Disorders of Motion. — {a) Paralyses. — These may be hemiplegic,
paraplegic, or monoplegic. Hysterical diplegia is extremely rare. The
paralysis either sets in abruptly or gradually, and may take weeks to attain
its full development. Tliere is no type or form of organic imralysis which
may not he simulated in hysteria. According to Weir Mitchell, the hemi-
plegias are most frequent in the ratio of four on the left to one on the
right side. The face is not affected ; the neck may be involved, but the
leg suffers most. Sensation is either lessened or lost on the affected side.
The hysterical paraplegia is more common than hemiplegia. The loss of
power is not absolute ; the legs can usually be moved, but do not support
the patient. The reflexes may be increased, though the knee-jerk is often
normal. A spurious ankle clonus may sometimes be present. The feet
are usually extended and turned inward in the equino-varus position. The
muscles do not waste and the electrical reactions are normal. Other mani-
festations, such as paralysis of the bladder or aphonia, are usually associ-
ated with the hysterical paraplegia. Hysterical monoplegias may be facial,
crural, or brachial. A condition of ataxia sometimes occurs with paresis.
The incoordination may be a marked feature, and there are usually sen-
sory manifestations.
{b) Contractures and Spasms. — An extraordinary variety of spas-
970 DISEASES OF THE NERVOUS SYSTEM.
modic affections occurs in hysteria, of whicli the most common are the
following : The hysterical contractures may attack almost any group of
voluntary muscles and be of the hemiplegic, paraplegic, or monoplegic
type. They may come on suddenly or slowly, persist for months or years,
and disappear rapidly. The contracture is most commonly seen in the
arm, which is flexed at the elbow and wrist, and the fingers tightly grasp
the thumb in the palm of the hand ; more rarely the terminal phalanges
are hyperextended as in athetosis. It may occur in one or in both legs,
more commonly the former. The ankle clonus is present ; the foot is
inverted and the toes are strongly flexed. These cases may be mistaken
for lateral sclerosis and the difficulty in diagnosis may really be very great.
The spastic gait is very typical, and with the exaggerated knee-jerk and
ankle clonus the picture may be characteristic. In 1879 I frequently
showed such a case at the Montreal General Hospital as a typical example
of lateral sclerosis. The condition persisted for more than eighteen months
and then disappeared completely. Other forms of contracture may be in
the muscles of the hip, shoulder, or neck ; more rarely in those of the jaws
— hysterical trismus — or in the tongue. Remarkable indeed are the local
contractures in the diaphragm and abdominal muscles, producing a phan-
tom tumor, in w^hich just below and in the neighborhood of the umbilicus
is a firm, apparently solid growth. According to Gowers, this is produced
by relaxation of the recti and a spasmodic contraction of the diaphragm,
together with inflation of the intestines with gas and an arching forward
of the vertebral column. They are apt to occur in middle-aged women
about the menopause, and are frequently associated with the symptoms of
spurious pregnancy — pseudo-cyesis. The resemblance to a tumor may be
striking, and I have known skilful diagnosticians to be deceived. The
only safeguard is to be found in complete anaesthesia, when the tumor
entirely disappears. Some years ago I went by chance into the operating-
room of a hospital and found a patient on the table under chloroform and
the surgeon prepared to perform ovariotomy. The tumor, however, had
completely disappeared with full anaesthesia. Mitchell has reported an
instance of a phantom tumor in the left pectoral region just above the
breast, which was tender, hard, and dense.
Clonic spasms are more common in hysteria in this country than
contractures. The following are the important forms : Rhythmic hyster-
ical spasm. This, unfortunately, is sometimes known as rhythmic chorea
or hysterical chorea. The movements may be of the arm, either flexion
and extension, or, more rarely, pronation and supination. Clonic contrac-
tions of the sterno-cleido-mastoid or of the muscles of the jaws or of the
rotatory muscles of the head may produce rhythmic movements of these
])arts. The spasm may be in one or both psoas muscles, lifting the leg in
a rhythmic manner eight or ten times in a minute. In other instances
the muscles of the trunk are affected, and every few moments there is a
bowing movement — salaam convulsions — or the muscles of the back may
HYSTERIA. 971
contract, causing strong arching of tfic vertebral column and retraction
of the head. 'J'hese movements may often alternate, as in a case in my
wards, in which the j)atient on fine days had regular salaam convul-
sions, while on wet days the rhythmic spasm was in the muscles of the
back and neck. Mitchell has described a rotatory spasm in which the
patient rotated involuntarily, usually to the left. More unusual cases are
those in which the contractions closely simulate paramyoclonus multiplex.
A characteristic example of this was recently at my clinic. Ilysterical
athetosis is a rare form of spasm. Tremor may be a pure hysterical mani-
festation, occurring either alone or with paralysis and contracture. It
most commonly involves the hands and arms ; more rarely the head and
legs. The movements are small and quick. Volitional or intentional
tremor may exist, simulating closely the movements of insular sclerosis.
Buzzard states that many instances of this disease in young girls are mis-
taken for hysteria.
(2) Disorders of Sensation. — Aoicssthesia is most common, and usually
confined to one half of the body. It may not be noticed by the patient.
Usually it is accurately limited to the middle line and involves the mucous
surfaces and deeper parts. The conjunctiva, however, is often spared.
There may be hemianopia. This symptom may come on slowly or follow
a convulsive attack. Sometimes the various sensations are dissociated and
the anesthesia may be only to pain and to touch. The skin of the affected
side is usually pale and cool, and a pin-prick may not be followed by blood.
With the loss of feeling there may be loss of muscular power. Curious
trophic changes may be present, as in an interesting case of Weir Mitch-
ell's, in which there was unilateral swelling of the hemiplegic side.
A phenomenon to which much attention has been paid is that of trans-
ference. By metallotherapy, the application of certain metals, the anass-
thesia or analgesia can be transferred to the other side of the body. It
has been shown, however, that this phenomenon may be caused by the
electro-magnet and by wood and various other agents, and is probably
entirely a mental effect. The subject has no practical importance, but it
remains an interesting and instructive chapter in Gallic medical history.
HypercBstliesia. — Increased sensitiveness and pains occur in various
parts of the body. One of the most frequent complaints is of pain in the
head, usually over the sagittal suture, less frequently in the occiput. This
is described as agonizing, and is compared to the driving of a nail into the
part ; hence the name clavus hystericus. Neuralgias are common. Hy-
peraesthetic areas, the hysterogenic points, exist on the skin of the thorax
and abdomen, pressure upon Avhich may cause minor manifestations or
even a convulsive attack. Increased sensitiveness exists in the ovarian
region, but is not peculiar to hysteria. Pain in the back is an almost con-
stant complaint of hysterical patients. The sensitiveness may be limited
to certain spinous processes, or it may be diffuse. In hysterical women
the pains in the abdomen may simulate those of gastralgia and of gastric
972 DISEASES OF THE NERVOUS SYSTEM.
ulcer, or the condition may be almost identical with that of peritonitis ;
more rarely the abdominal pains closely resemble those of appendix
disease.
Special Senses. — Disturbances of taste and smell are not uncommon
and may cause a good deal of distress. Of ocular symptoms, retinal hyper-
esthesia is the most common, and the patients always prefer to be in a
darkened room. Retraction of the field of vision is common and usually
follows a convulsive seizure. It may persist for years. The color percep-
tion may be normal even with complete anaesthesia, and in this country
the achromatopsia does not seem to be nearly so common an hysterical
manifestation as in Europe. Hysterical deafness may be complete and
mav alternate or come on at the same time with hysterical blindness.
(3) Visceral Manifestations. — Respiratory Apparatus. — Of disturb-
ances in the respiratory rhythm, the most frequent, perhaps, is an exaggera-
tion of the deeper breath, which is taken normally every fifth or sixth
inspiration, or there may be a " catching " breathing, such as is seen when
cold water is poured over a person. Hysterical dyspnoea is readily recog-
nized, as there is no special distress and the pulse is usually normal. I
have met with a remarkable case following trauma in which the respira-
tions rose above one hundred and thirty in the minute. Among larpigeal
manifestations aphonia is the most frequent and may persist for months
or even years without other special symptoms of the disease. Spasm of
the muscles may occur with violent inspiratory efforts and great distress,
and may even lead to cyanosis. Hiccough, or sounds resembling it, may be
present for weeks or months at a time. Among the most remarkable of
the respiratory manifestations are the hysterical cries. These may mimic
the sounds produced by animals, such as barking, mewing, or grunting,
and in France epidemics of them have been repeatedly observed. Extraor-
dinary cries may be produced, either inspiratory or expiratory. I saw
at AYagner's clinic at Leipsic a girl of thirteen or fourteen, who had for
many weeks given utterance to a remarkable inspiratory cry somewhat like
the whoop of whooping-cough, but so intense that it was heard at a long
distance. It was incessant, and the girl was worn to a skeleton. Attacks
of gaping, yawning, and sneezing may also occur.
The hysterical cough is a frequent symptom, particularly in young
girls. It may occur in paroxysms, but is often a dry, persistent, croaking
cough, extremely monotonous and unpleasant to hear. Sir Andrew Clark
has called attention to a loud, barking cough occurring about the time
of puberty, chiefly in boys belonging to neurotic families. The attacks,
wliich last about a minute, recur frequently.
There is a peculiar form of hnemoptysis which may be very deceptive
and lead to the diagnosis of pulmonary disorders. Wagner describes the
sputum as a pale-red fluid — not so bright in color as in ordinary haemop-
tysis, and on settling presents a reddish-brown sediment. It contains par-
ticles of food, pavement epithelium, red corpuscles, and micrococci, but
HYSTERIA. 973
no cylindrical or ciliated epitlielium. It probably comes from the moutli
or pharynx.
Digestive System. — Disturbed or depraved appetite, dyspepsia, and
gastric pains are common in hysterical patients. Tlie patient may have
difficulty in swallowing the food, apparently from spasm of the gullet.
There are instances in which the food seems to be expelled before it reaches
the stomach. In other cases there is incessant gagging. In the hysterical
vomiting the food is regurgitated without much effort and without nausea.
This feature may persist for years without great disturbance of nutrition.
The most striking and remarkable digestive disturbance in hysteria is the
anorexia nervosa described by Sir William Gull. " To call it loss of appe-
tite— anorexia — but feebly characterizes the symptom. It is rather an
annihilation of appetite, so complete that it seems in some cases impossible
ever to eat again. Out of it grows an antagonism to food which results
at last and in its worst forms in spasm on the approach of food, and this in
turn gives rise to some of those remarkable cases of survival for long periods
without food " (Mitchell). As this goes on there may be an extreme degree
of muscular restlessness, so that the patients wander about until exhausted.
This feature has not been present in the cases which have come under
my observation. Nothing more pitiable is to be seen in practice than an
advanced case of this sort. It is usually in a young girl, sometimes as
early as the eleventh or twelfth, more commonly between the fifteenth and
twentieth years. The emaciation is frightful, and scarcely exceeded by
that of cancer of the oesophagus. The patient finally takes to bed, and in
extreme cases lies upon one side wdth the thighs and legs flexed, and con-
tractures may occur. Food is either not taken at all or only upon urgent
compulsion. The skin becomes wasted, dry, and covered with bran-like
scales. No food may be taken for several weeks at a time, and attempts to
feed may be followed by severe spasms. Although the condition looks so
alarming, these cases, when removed from their home surroundings and
treated by Weir Mitchell's method, sometimes recover in a remarkable
way. Death, however, may follow with extreme emaciation. In a
fatal case recently under my care the girl weighed only forty-nine pounds.
No lesions were found post mortem.
Among intestinal symptoms flatulency is one of the most distressing,
and is usually associated with the condition of peristaltic unrest (Kiiss-
maul). Frequent discharges of faeces may be due to disturbance in either
the small or large bowel. An obstinate form of diarrhoea is found in some
hysterical patients, which proves very intractable and is associated espe-
cially with the taking of food. It seems an aggravated form of the loose-
ness of bowels to which so many nervous people are subject on emotion
or the tendency which some have to diarrhoia immediately after eating. An
entirely different form is that produced by what Mitcihell calls the irritable
rectum, in which scybala are passed frequently during the day, sometimes
with great violence. Constipation is more frequent, however, and may be
974: DISEASES OF THE NERVOUS SYSTEM.
due to a loss of power in tlie muscles of the bowel or in the abdominal
muscles. In extreme cases the bowels may not be moved for two or
three weeks, leading to great accumulation of fseces. Other disturbances
are ano-spasm or intense pain in the rectum apart from any fissure.
Cardio-vascular. — Rapid action of the heart on the slightest emotion,
with or without the subjective sensation of palpitation, is often a source
of great distress. A slow pulse is less frequent. Pains about the heart
may simulate angina, the so-called hysterical or pseudo-angina, which has
already been considered. Flushes in various parts are among the most
common symptoms, and may be seen in the head, back, hands, or feet.
Sweating occasionally occurs.
Among the more remarkable vaso-motor phenomena are the so-called
stigmata or haemorrhages in the skin, such as were present in the cele-
brated case of Louise Lateau. In many cases these are undoubtedly
fraudulent, but if, as appears credible, such bleeding may exist in the
hypnotic trance, there seems no reason to doubt its occurrence in the
trance of prolonged religious ecstasy.
Joint Affections. — To Sir Benjamin Brodie and Sir James Paget we
owe the recognition of these extraordinary manifestations of hysteria.
Perhaps no single affection has brought more discredit upon the profes-
sion, for the cases are very refractory, anc" finally fall into the hands of a
charlatan or faith-healer, under whose touch the disease may disappear at
once. Usually it affects the knee or the hip, and may follow a trifling
injury. The joint is usually fixed, sensitive, and swollen. The surface
may be cool, but sometimes the local temperature is increased. To the
touch it is very sensitive and movement causes great pain. In protracted
cases the muscles about the joint are somewhat wasted, and in conse-
quence it looks larger. The pains are often nocturnal, at which time the
local temperature may be much increased. While, as a rule, neuromimetic
joints yield to proper management, there are interesting instances in the
literature in which organic change has succeeded the functional disturb-
ance. In the remarkable case reported in Weir Mitchell's lectures, the
hysterical features were pronounced, and, on account of the chronicity,
the disease of the knee-joint was considered organic by such an authority
as Billroth. Sands operated and found the joint surfaces normal, and
the thickening to be due to non-tuberculous inflammatory products out-
side the capsule.
Mental Symptoms. — The psychical condition of an hysterical patient
is always abnormal, and the disease occupies the ill-defined territory be-
tween sanity and insanity. In a large number of cases the patients are
really insane, particularly in the perversion witnessed in the moral sphere.
Xot the slightest dependence can be placed upon their statements, and
they will for months or years deceive friends, relatives, and physician.
This appears to result partly, but not wholly, from a morbid craving for
sympathy. It is really due to an entire unhinging of the moral nature.
HYSTERIA. 9Y5
Hysterical patients may become insane and display persistent hallucina-
tions and delirium, alternating perhaps with emotional outbursts of an
aggravated character. For weeks or months they may be confined to bed,
entirely oblivious to their surroundings, with a delirium which may simu-
late that of delirium tremens, particularly in being associated with loath-
some and unpleasant animals. The nutrition may be maintained, but in
these cases there is always a very heavy, foul breath. With seclusion and
care recovery usually takes place within three or four months. At the
onset of these attacks and during convalescence the patients must be
incessantly watched, as a suicidal tendency is by no means uncommon.
Of hysterical manifestations in the higher centres that of trance is the
most remarkable. This may develop spontaneously without any convul-
sive seizure, but more frequently, in this country at least, it follows hys-
teroid attacks. Catalepsy, a condition in which the limbs are plastic and
remain in any position in which they are placed, may or may not be pres-
ent with this condition.
The Metaholism in Hysteria. — The studies of Gilles de la Tourette
and Cathelineau, under Charcot's direction, have shown that in the ordi-
nary forms of hysteria the urine does not show quantitative or qualitative
changes, but in the severe types, characterized by convulsions, etc., there
are important modifications : reduction in the urates and phosphates ; the
ratio of the earthy to the alkaline phosphates, normally 1 : 3, is 1 : 2, or
even 1:1. The urine is also reduced in amount. They think that these
changes might sometimes serve to differentiate convulsive hysteria from
epilepsy, in which there is always an increase in the solid constituents
after a seizure.
Hysterical Fever. — In hysteria the temperature, as a rule, is normal.
The cases with fever may be grouped as follows : {a) Instances in which
the fever is the sole manifestation. These are rare, but I have seen at
least two cases in which the chronic course, the retention of the nutrition,
and the entirely negative condition of the organs left no other diagnosis
possible. In a case recently under observation the patient has had for four
or five years an afternoon rise of temperature, reaching usually to 102° or
103°. She was well nourished and presented no pronounced hysterical
symptoms, but there was a marked neurotic history on one side and a form
of interrupted sighing respiration so often seen in hysteria.
{h) Cases of hysterical fever with spurious local manifestations. These
are very troublesome and deceptive cases. The patient may be suddenly
taken ill with pain in various regions and elevation of temperature. The
case may simulate meningitis. There may be pain in the head, vomiting,
contracted pupils, and retraction of the neck — symptoms which may per-
sist for weeks — and some anomalous manifestation during convalescence
may alone indicate to the physician that he has had to deal with a case of
hysteria, and has not, as he perhaps flattered himself, cured a case of men-
ingitis. Mary Putnam Jacobi, in a recent article on hysterical fever,
97G DISEASES OF THE NERVOUS SYSTEM.
mentions a case in the service of Cornil which was admitted with dyspnoea,
slight cyanosis, and a temperature at 39° C. The condition proved to be
hysterical. There is also an hysterical pseudo-phthisis with pain in the
chest, slight fever, and the expectoration of a blood-stained mucus. The
cases of hysterical peritonitis may also show fever. Only by incessant
watchfulness can mistakes be prevented in these cases.
(c) Hysterical Hyjierpyrexia. — It is a suggestive fact that the cases of
paradoxical temperatures reported of late years, in which the thermometer
has registered 112° to 120° or more, have been in Avomen. Fraud has
been practised in some of these, but in others the high fever has been as-
sociated with neurotic features and may really have been of an hysterical
character.
Diagnosis. — Inquiry into the occurrence of previous manifestations
and the mental conditions may give important information. These ques-
tions, as a rule, should not be asked the mother, who of all others is least
likely to give satisfactory information about the patient's condition. The
occurrence of the globus hystericus, of emotional attacks, of weeping and
crying, are always suggestive. The points of difference between the con-
vulsive attacks and true epilepsy- were referred to in their description,
and as a rule little difficulty is experienced in distinguishing between the
two conditions. The hysterical paralyses are very variable and apt to be
associated with anaesthesia. The contractures may at times be very decep-
tive, but the occurrence of areas of anaesthesia, of retraction of the visual
field, and the development of minor hysterical manifestations, give valua-
ble indications. The contractures disappear under full anaesthesia. Spe-
cial care must be taken not to confound the spastic paraplegia of hysteria
with lateral sclerosis.
The visceral manifestations are usually recognized without much diffi-
culty. The practitioner has constantly to bear in mind the strong tend-
ency in hysterical patients to practise deception.
Treatment. — The prophylaxis in hysteria may be gathered from the
remarks on the relation of education to the disease. The successful treat-
ment of hysteria demands qualities possessed by few physicians. The first
element is a due appreciation of the nature of the disease on the part of
the physician and friends. It is pitiable to think of the misery which has
been inflicted on these unhappy victims by the harsh and unjust treat-
ment which has resulted from false viev/s of the nature of the trouble ;
on the other hand, worry and ill-health, often the wrecking of mind,
body, and estate, are entailed upon the near relatives in the nursing of a
protracted case of hysteria. The minor manifestations, attacks of the
vapors, the crying and weeping spells, are not of much moment and
rarely require treatment. The physical condition should be carefully
looked into and the mode of life regulated so as to insure system and
order in everything. A congenial occupation offers the best remedy for
many of these manifestations. Any functional disturbance should be at-
HYSTERIA. 9Y7
tended to and a course of tonics prescribed. Special attention should be
paid to the action of the bowels.
Valerian and asafoetida are often of service. For the pains in various
parts, particularly in the back, the thermo-cautery and static electricity
will be found invaluable. Morphia should be withheld. In the convulsive
seizures, particularly in the minor forms, it is often best, after settling the
patient comfortably, to leave her. When she comes to, and finds her-
self alone and without sympathy, the attacks are less likely to be repeated.
There is, as a rule, no cure for the hysterical manifestations of women,
otherwise in good health, who are, as Mitchell says, " fat and ruddy, with
sound organs and good appetites, but ever complain of pains and aches,
and ever liable on the least emotional disturbance to exhibit a quaint
variety of hysterical phenomena."
To treat hysteria as a physical disorder is, after all, radically wrong.
It is essentially a mental and emotional anomaly, and the important ele-
ment in the treatment is moral control. At home, surrounded by loving
relatives who misinterjDret entirely the symptoms and have no appreciation
of the nature of the disease, the severer forms of hysteria can rarely be
cured. The necessary control is impossible ; hence the special value of
the method introduced by Weir Mitchell, which is particularly applicable
to the advanced cases which have become chronic and bedridden. The
treatment consists in isolation, rest, diet, massage, and electricity. Sepa-
ration from friends, and sympathetic relatives must be absolute, and can
rarely, if ever, be obtained in the individual's home. An essential element
in the treatment is an intelligent nurse. Xo small share of the success
which has attended the author of this plan has been due to the fact that
he has persistently chosen as his allies bright, intelligent women. The
details of the plan are as follows : The patient is confined to bed and not
allowed to get up, nor, at first, in aggravated cases, to read, write, or even
to feed herself. Massage is used daily, at first for twenty minutes or half
an hour, subsequently for a longer period. It is essential as a substitute
for exercise. The induction current is applied to the various muscles and
to the spine. Its use, however, is not so essential as that of massage. The
diet may at first be entirely of milk, four ounces every two hours. It is
better to give skimmed milk, and it may be diluted with soda water or
barley water and, if necessary, peptonized. After a week or ten days the
diet may be increased, the amount of milk still being kept up. A chop
may be given at midday, a cup of coffee or cocoa with toast or bread and
butter or a biscuit with the milk. The patients usually fatten rapidly as
the solid food is added, and with the gain there is, as a rule, a diminution
or cessation of the Ticrvous symptoms, 'I'lie milk is the essential element
in the diet, and is itself amply sufficient.
The remarkable results obtained by this method are now universally
recognized. The i)lan is more applicable to the lean than to fat, flabby
hysterical patients. Not only is it suitable for the more obstinate varie-
978 DISEASES OF THE NERVOUS SYSTEM.
ties of hysteria with bodily manifestations, but in the cases with mental
symptoms the seclusion and separation from relatives and friends are par-
ticularly advantageous. In the hysterical vomiting Debove's method of
forced feeding may be used with benefit. For the innumerable minor
manifestations of hysteria and for the simulations the indications for treat-
ment are usually clear. Of late, hypnotism has been extensively used in
the treatment of hysteria. Occasionally in cases of hysterical contractions
or paralysis it is of benefit, but any one who has seen the development of
this method as practised at present in France must feel that it is a two-
edged sword and that the constant repetition in the same patient is fraught
with danger. In the cases which we have tried here the success has not
been marked.
Xll, NEURASTHENIA.
Definition. — A condition of weakness or exhaustion of the nervous
system.
The term, invented by Beard, covers an ill-defined, motley group of
svmptoms, which may be either general and the expression of derange-
ment of the entire system,' or local, limited to certain organs ; hence the
terms cerebral, spinal, cardiac, and gastric neurasthenia. In certain re-
spects it is the physical counterpart of insanity. As the essential feature
in the latter condition is the abnormal response to stimuli, from within or
without, upon the higher centres presiding over the mind, so neurasthenia
appears to be the expression of a morbid, unhealthy reaction to stimuli
acting on the nervous centres which preside over the functions of organic
life. No hard and fast line can be drawn between neurasthenia and cer-
tain mental states, particularly hysteria and hypochondria.
Etiology. — Although the causes are apparently varied, they may be
grouped as hereditary and acquired.
(a) Hereditary. — We do not all start in life with the same amount of
nerve capital. Parents who have been the subjects of nervous complaints
or of mental troubles transmit to their children an organization which
is defective in what, for want of a better term, we must call " nerve force."
Such individuals start handicapped, and furnish a considerable proportion
of our neurasthenic patients. So long as they are content to transact a
moderate business with their life capital, all may go well, but there is no
reserve, and in the emergencies which constantly arise in the exigencies
of modern life these small capitalists go under and come to us as bank-
rupts.
{h) Acquired. — The functions, though perverted most readily in per-
sons who have inherited a feeble organization, may also be damaged by
exercise which is excessive in proportion to the strength — i. e., by strain.
The cares and anxieties attendant upon the gaining of a livelihood may
be borne without distress, but in many persons the strain becomes excess-
NEURASTHENIA. 979
ive and is first manifested as worry. The individual loses the distinction
between essentials and non-essentials, trifles cause annoyance, and the
entire organism reacts with unnecessary readiness to slight stimuli, and is
in a state which the older writers called irritable weakness. If such a
condition be taken early and the patient given rest, the balance is quickly
restored. In this group may be placed a large proportion of the neuras-
thenics which we see in this country, particularly among business men.
Other causes more subtle, yet potent, and less easily dealt with, are the
worries attendant upon love affairs, religious doubts, and the sexual pas-
sion.
Symptoms. — These are extremely varied, and may be general or
localized ; more often a combination of both. The appearance of the
patient is suggestive, sometimes characteristic, but difficult to describe.
Loss of weight and slight anaemia may be present. The physical debility
may reach a high grade and the patient may be confined to bed. Men-
tally the patients are usually low-spirited and despondent, in women fre-
quently emotional.
The local symptoms may dominate the situation, in w^hich case the
clinical picture is of the so-called cerebral or spinal neurasthenia. Other
local forms are cardio-vascular, gastric, and sexual.
In the cerebral form the symptoms are chiefly connected with an
inability to perform the ordinary mental work. Thus a row" of figures
cannot be correctly added, the dictation or the writing of a few letters is a
source of the greatest worry, the transaction of petty details in business is
a painful effort, and there is loss of power of fixed attention. With this
condition there may be no headache, the aj^petite may be good, and the
patient may sleep well. As a rule, however, there are sensations of fulness
and weight or flushes, if not actual headache. Sleeplessness is a frequent
concomitant, and may be the first manifestation. Some of these patients
are good-tempered and cheerful, but a majority are moody, irritable, and
depressed.* The special senses may be disturbed, particularly vision. An
aching or weariness of the eyeballs after reading a few minutes or flashes
of light are common symptoms. A difference between the pupils may be
present.
When the spinal symptoms predominate — spinal irritation or spinal
neurasthenia — in addition to many of the features just mentioned, the
patients complain of weariness on the least exertion, of weakness, pain in
the back, and of aching pains in the legs. There may be spots of local
tenderness on the spine. Occasionally there may be disturbances of sen-
sation, particularly a feeling of numbness and tingling, and the reflexes
may be increased. The aching pain in the back or in the back of the
neck is the most constant complaint in these cases. In women it is often
* For an exhaustive consideration of the mental symptoms of neurasthenia, see the
Shattuck Lecture, by Cowles. Boston Medical and Surgical Journal, 1801.
62
980 DISEASES OF THE NERVOUS SYSTEM.
impossible to say whether this condition is one of neurasthenia or hys-
teria.
In other cases the cardio-vascular symptoms are the most distressing,
and may occur with only slight disturbance of the cerebro-spinal functions,
though the conditions may be combined. Palpitation of the heart, irregu-
lar and very rapid action, and pains in the cardiac region are the most
common symptoms. The slightest excitement may be followed by in-
creased action of the heart, and the patients frequently have the idea that
they suffer from serious disease of this organ.
Vaso-motor disturbances constitute a special feature of many cases.
Flushes of heat and transient hyperaemia of the skin may be very distress-
ing symptoms. Profuse sweating may occur, either local or general, and
sometimes nocturnal. The pulse may show interesting features, owing
to the extreme relaxation of the peripheral arterioles. The arterial throb-
bing may be everywhere visible, almost as much as in aortic insufficiency.
The pulse, too, may under these circumstances have a somewhat water-
hammer quality. The capillary pulse may be seen in the nails, on the
lips, or on the margins of a line drawn upon the forehead, and I have on
several occasions seen pulsation in the veins of the back of the hand.
A characteristic symptom in some cases is the tlirobMng aorta. The epi-
gastric pulsation may be extremely forcible and suggest the existence of
abdominal aneurism. The subjective sensations associated with it may be
very unpleasant, particularly when the stomach is empty.
The general features of gastro-intestinal neurasthenia have been dealt
with under the section of nervous dyspepsia. The connection of these
cases with dilatation of the stomach, floating kidney, and the condition
which Glenard calls eyiteroi^tosis has already been mentioned.
Sexual neurasthenia is a condition in which there is an irritable weak-
ness of the sexual organs manifested by nocturnal emissions, unusual de-
pression after intercourse, and often by a distressing dread of impotence.
The mental condition of these patients is most pitiable, and they fall an
easy prey to quacks and charlatans of all kinds.
In all forms of neurasthenia the condition of the urine is important
Many cases are complicated w^ith the symptoms of the condition known
as lithcTmia, and so marked may this be that some have indeed made a
special form of lithaemic neurasthenia. Polyuria may be present, but is
more common in hysteria. With disturbed digestion the urates and oxa-
lates may be in excess.
The diafjnosis is readily made. It is sometimes difficult to distinguish
the cases from hysteria, and this is not surprising, as we cannot always
differentiate the two conditions. Neurasthenia occurs chiefly in men ; in
fact, it is in many ways in them the equivalent of hysteria.
THE TRAUMATIC NEUROSES. 981
XIII. THE TRAUMATIC NEUROSES
{Railway Brain and Railway Spine; Traumatic Jlysteria).
Definition. — A morbid condition following shock which presents the
symptoms of neurasthenia or hysteria or of both. The condition is known
as " railway brain " and " railway spine."
Erichsen regarded the condition as the result of inflammation of the
meninges and cord, and gave it the name railway spine. Walton and
J. J. Putnam, of Boston, were the first to recognize the hysterical nature
of many of the cases,* and to Westphal's pupils we owe the name traumatic
neurosis.
Etiology. — The condition follows an accident, often in a railway
train, in which injury has been sustained, or succeeds a shock or concus-
sion, from which the patient may apparently not have suffered in his body.
A man may appear perfectly well for several days, or even a week or
more, and then develop marked symptoms of the neurosis. Bodily shock
or concussion is not necessary. The affection may follow a profound
mental impression ; thus, an engine driver ran over a child, and received
thereby a very severe shock, subsequent to which tlie most pronounced
symptoms of neurasthenia developed. Severe mental strain combined with
bodily exposure may cause it, as in a case of a naval officer who was
wrecked in a violent storm and exposed for more than a day in the rig-
ging before he was rescued. A slight blow, a fall from a carriage or on
the stairs may suffice.
Symptoms. — The cases may be divided into three groups : simple
neurasthenia, cases with marked hysterical manifestations, and cases with
severe symptoms indicating or simulating organic disease.
{a) Simple Traumatic Neurasthenia. — The first symptoms usually de-
velop a few weeks after the accident, which may or may not have been
associated with an actual trauma. The patient complains of headache
and tired feelings. He is sleepless and finds himself unable to concentrate
his attention properly upon his work. A condition of nervous irritability
develops, which may have a host of trivial manifestations, and the entire
mental attitude of the person may for a time be changed. He dwells con-
stantly upon his condition, gets very despondent and low-spirited, and in
extreme cases melancholia may develop. He may complain of numbness
and tingling in the extremities, and in some cases of much pain in the
back. The bodily functions may be well performed, though such patients
usually have, for a time at least, disturbed digestion and loss in weight.
The physical examination may be entirely negative. The reflexes are
slightly increased, as in ordinary neurasthenia. The pupils may be un-
crjual ; the cardio- vascular changes already described in neurasthenia may
be present in a marked degree. According as tlie symptoms are more
* See La Neurasthenic, par L. Bouverct, Paris, 1891.
982 DISEASES OF THE NERVOUS SYSTEM.
spinal or more cerebral, the condition is known as railway brain or railway
S2)ine.
(2) Cases loith Marked Ilysterical Features. — Following an injury of
any sort, neurasthenic symptoms, like those described above, may develop,
and in addition symptoms regarded as characteristic of hysteria. The
emotional element is prominent, and there is but slight control over the
feelings. The patients have headache, backache, and vertigo. A violent
tremor may be present, and indeed constitutes the most striking feature of
the case. I have recently seen an engineer who developed subsequent to
an accident a series of nervous phenomena, but the most marked feature
was an excessive tremor of the entire body, which was specially manifest
during emotional excitement. The most pronounced hysterical symptoms
are the sensory disturbances. As first noted by Putnam and Walton,
hemiansesthesia may occur as a sequence of traumatism. This is a com-
mon symptom in France, but rare in England and in this country. In
a considerable number of cases of traumatic neuroses which I have seen
only one presented typical hemianaesthesia. A second, more common,
manifestation is limitation of the field of vision.
Eemarkable disturbances may develop in some of these cases. A few
months ago I saw a man who had been struck by an electric car, whose
chief symptom was an extraordinary increase in the number of respira-
tions. He was a stout, powerfully built man, and presented practically no
other symptom than dyspnoea of the most extreme grade. At the time of
observation his respirations were over 130 per minute, and he stated that
they had been counted at over 150.
(3) Cases in loliicli the Symptoms suggest Organic Disease of the
Brain and Cord. — As a result of spinal concussion, without fracture or
external injury, there may subsequently develop symptoms suggestive of
organic disease, which may come on rapidly or at a late date. In a case
reported by Leyden the symptoms following the concussion were at first
slight and the patient was regarded as a simulator, but finally the condi-
tion became aggravated and death resulted. The post-mortem showed a
chronic pachymeningitis, which had doubtless resulted from the accident.
The cases in this group about which there is so much discussion are those
which display marked sensory and motor changes. Following an accident
in which the patient has not received external injury a condition of ex-
citement may develop within a week or ten days ; he complains of head-
ache and backache, and on examination sensory disturbances are found,
either hemianaesthesia or areas on the skin in which the sensation is much
benumbed ; or painful and tactile impressions may be distinctly felt in
certain regions, and the temperature sense is absent. The distribution
may be bilateral and symmetrical in limited regions or hemiplegic in type.
Limitation of the field of vision is usually marked in these cases, and there
may be disturbance of the senses of taste and smell. The superficial re-
flexes may be diminished ; usually the deep reflexes are exaggerated. The
THE TRAUMATIC NEUROSES. 983
pupils may be unequal ; the motor disturbances are variable. The French
writers describe cases of monoplegia with or without contracture, symp-
toms upon which Charcot lays great stress as a manifestation of profound
hysteria. The combination of sensory disturbances — anaesthesia or hyper-
aesthesia — with paralysis, particularly if monoplegic, and the occurrence of
contractures without atrophy and with normal electrical reactions, may be
regarded as distinctive of hysteria.
In rare cases following trauma and succeeding to symptoms which may
have been regarded as neurasthenic or hysterical, there are organic changes
which may prove fatal. That this sequence occurs is demonstrated clearly
by recent post-mortem examinations. The features upon which the
greatest reliance can be placed as indicating definite organic change are
optic atrophy, bladder symptoms, particularly in combination with tremor,
paresis, and exaggerated reflexes.
. The anatomical changes in this condition have not been very definite.
When death follows spinal concussion within a few days there may be no
apparent lesion, but in some instances the brain or cord has shown punc-
tiform haemorrhages. Edes has reported four cases in which a gradual
degeneration in the pyramidal tracts followed concussion or injury of the
spine ; but in all these cases there was marked tremor and the spinal
symptoms developed early or followed immediately upon the accident.
Post-mortems upon cases in which organic lesions have supervened upon
a traumatic neurosis are extremely rare. Bernhardt reports an instance
of a man, aged thirty-three, who in 1886 received a kick from a horse
on the epigastrium and subsequently developed the symptom-complex of
neurasthenia and hysteria with attacks of vertigo and great psychical de-
pression. He afterward had more marked mental symptoms and attacks
of unconsciousness. He committed suicide and the brain and cord showed
a beginning multiple sclerosis in the white matter, which was possibly
associated with an advanced grade of arterio-sclerosis. In a second case
a man, aged forty-two, received a shock in a railway accident in July,
1884. He was rendered unconscious and had a slight injury in the but-
tock region. In a few weeks symptoms of traumatic neurosis developed,
particularly great depression of spirits, with headache and sensory disturb-
ances in the feet and hands. Tremor and great weakness were com-
plained of when he attempted to work. There was no increase in the
reflexes. The case was regarded as an instance of simulation and a defect
in objective symptoms favored this view. Subsequently this judgment
was reversed, but he did not improve. He died in January, 1889, with
symptoms of cardiac dyspnoea. Macroscopically the brain and cord ap-
peared normal. There was extreme arterio-sclerosis, particularly of the
vessels of the brain and cord. In the latter there were scattered areas of
degeneration in the white substance, and degeneration in the sympathetic
ganglia.
I have entered somewhat fully into this question because of its extreme
984: DISEASES OP THE NERVOUS SYSTEM.
importance and on account of the paucity of the observations upon cases
which have subsequently developed symptoms of organic disease. Exam-
ples of it are extremely rare. So far as I know no case with autopsy has
been reported in this country, nor have I seen an instance in which the
clinical features pointed to an organic disease which had followed upon a
traumatic neurosis.
Diagnosis. — A condition of fright and excitement following an acci-
dent may persist for days or even weeks, and then gradually pass away.
The symptoms of neurasthenia or of hysteria which subsequently develop
present nothing peculiar and are identical with those which occur under
other circumstances. Care must be taken to avoid simulation, and, as in
these cases the condition is largely subjective, this is sometimes extremely
difficult. In a careful examination a simulator will often reveal himself
by exaggeration of certain symptoms, particularly sensitiveness of the
spine, and by increasing voluntarily the reflexes. It may require a careful
study of the case to determine whether the individual is honestly suffering
from the symptoms of which he complains. A still more important ques-
tion in these cases is, Has the patient organic disease ? The symptoms
given under the first two groups of cases may exist in a marked degree
and may persist for several years without the slightest evidence of organic
change. It must be noted that in the two autopsies above referred to the
patients were the subjects of extreme arterio-sclerosis, with which, in all
probability, the areas of multiple sclerosis were associated. Hemianaesthe-
sia, limitation of the field of vision, monoplegia with contracture, may all
be present as hysterical manifestations, from which recovery may be com-
plete. In our present knowledge the diagnosis of an organic lesion should
be limited to those cases in which optic atrophy, bladder troubles, and signs
of sclerosis of the cord are well marked — indications either of degeneration
of the lateral columns or of multiple sclerosis.
Prognosis. — A majority of patients with traumatic hysteria recover.
In railway cases, so long as litigation is pending and the patient is in the
hands of lawyers the symptoms usually persist. Settlement is often the
starting point of a speedy and perfect recovery. I have known return to
health after the persistence of the most aggravated symptoms with com-
plete disability of from three to five years' duration. On the other hand,
there are a few cases in which the symj)toms persist even after the litiga-
tion has been closed ; the patient goes from bad to worse and psychoses
develop, such as melancholia, dementia, or occasionally progressive paresis.
And, lastly, in extremely rare cases, organic lesions may develop as a
sequence of the traumatic neurosis.
The function of the physician acting as medical expert in these cases
consists in determining (a) the existence of actual disease, and {b) its char-
acter, whether simple neurasthenia, severe hysteria, or an organic lesion.
The outlook for ultimate recovery is good except in cases which present the
more serious symptoms above mentioned. Nevertheless, it must be borne
OTHER FORMS OP FUNCTIONAL PARALYSIS. 985
in mind that traumatic hysteria is one of the most intractable affections
which we are called upon to treat.
Treatment of Neurasthenia. — Many patients come under our
care a generation too late for satisfactory treatment, and it may be impos-
sible to restore the exhausted capital. In other instances, the recovery
takes place rapidly, the patient remains well for a few months or a year,
and then overwork, or even the ordinary wear and tear of life, again pros-
trates him. - Other persons drift into a condition of chronic invalidism or
become slaves to morphia or chloral. In the case of business or profes-
sional men, in whom the condition develops as a result of overwork or
overstudy, it may be sufficient to enjoin absolute rest with change of scene
and diet. A trip abroad, with a residence for a month or two in Switzer-
land, or, if there are symptoms of nervous dyspepsia, a residence at one of
the Spas, will usually prove sufficient. The excitement of the large cities
abroad should be avoided. Better still for these cases, if they carry it out,
is a life in the woods or on the plains. Three months of tent-life in the
Adirondacks or the same length of time in the Eocky Mountains will
sometimes cure the most marked cases of this kind. Such a plan is not,
however, within the circumstances of all. In a much larger class, includ-
ing a large proportion of neurasthenic women, a systematic Weir Mitchell
treatment rigidly carried out should be tried (see hysteria). For obstinate
and protracted cases, particularly if combined with the chloral or morphia
habit, no other plan is so satisfactory. The treatment of the gastric and
intestinal symptoms so important in this condition has already been con-
sidered. In milder grades of the condition massage alone will be found
very useful. For the irregular pains, particularly in the back and neck,
the thermo-cautery is invaluable. Medicines are of little avail. Strychnia
in full doses is often beneficial. For the relief of sleeplessness all possible
measures should be resorted to before the employment of drugs.
XIV. OTHER FORMS OF FUNCTIONAL PARALYSIS.
I. Periodical Paralysis.
I have already referred to the remarkable periodical paralysis of the
ocular muscles, which may recur at intervals for many years. There is a
form of periodical paralysis involving the general muscles, which may
recur with great regularity, and which is also a " family " affection. In
AVestphal's case, a boy of twelve, the attacks began in the eighth year, and
at first recurred every four or six weeks, and lasted from a few hours to
two days. Goldflam* has described a family in which twelve members
were affected with this disease, the heredity being through the mother.
* Zeitschrift fiir klinische Mcdicin, Bd. xix, 1891.
986 DISEASES OF THE NERVOUS SYSTEM.
Cousot has also met with a family in which the mother and four children
were attacked. The disease occurs in youth, and the tendency to the
attacks diminishes witli age.
The clinical picture is very much alike in all the recorded cases. The
paralysis involves, as a rule, the arms and legs. It comes on when the
patients are in full health, and without any apparent cause, often during
sleep. Sometimes it begins with weakness in the limbs, a sensation of
weariness and sleepiness, not often with sensory symptoms. The paralysis
is usually complete within the first twenty-four hours, beginning in the
leffs, to which in rare instances it is confined. The muscles of the neck
are sometimes involved, and occasionally those of the tongue and pharynx.
The cerebral nerves and the special senses are^ as a rule, uninvolved. The
attacks are afebrile, sometimes with low temperatures and slow pulse.
The deep reflexes are reduced, sometimes abolished, and the skin reflexes
may be feeble. One of the most remarkable features is the extraordinary
reduction or complete abolition of the faradic excitability, both of muscles
and of nerves.
Improvement begins sometimes in the course of a few hours or after a
day or two, and the paralysis disappears completely, and the patient is
perfectly well. As mentioned, the attacks may recur every few weeks, in
some instances even daily ; more commonly, an interval of one or two
weeks elapses between the attacks. Goldflam suggests that the paralysis is
due to an auto-intoxication, and that the poisonous material acts upon the
nerve-endings in the muscles. He has made experiments with the urine
of a case which showed that during the attacks the toxic properties of this
secretion were materially increased. From the recurring, periodic char-
acter of the attacks they have been supposed to be due to malaria, but of
this there is no evidence.
II. Astasia ; Abasia.
These terms, indicating respectively inability to stand and inability to
walk, have been applied by Charcot and Blocq to diseased conditions char-
acterized by loss of the power of standing or of walking with retention of
muscular power, coordination, and sensation. Blocq's definition is as fol-
lows : " A morbid state in which the impossibility of standing erect and
walking normally is in contrast with the integrity of sensation, of muscu-
lar strength, and of the coordination of the other movements of the lower
extremities." The condition forms a symptom group, not a morbid entity,
and is probably a functional neurosis. Knapp in a recent paper analyzes
the 50 cases reported in the literature. Twenty-five of these were in men,
25 in women. In 21 cases hysteria was present ; in 3, chorea ; in 2, epi-
lepsy ; and in 4, intention psychoses. As a rule, the patients, though able
to move the feet and legs perfectly when in bed, are either unable to walk
properly or cannot stand at all. The disturbances have been very varied,
RAYNAUD'S DISEASE. 987
and different forms have been recognized. The commonest, according to
Knapp's analysis of the recorded cases, is the paralytic, in which the legs
give out as the patient attempts to walk and " bend under him as if made
of cotton." " There is no rigidity, no spasm, no incoordination. In bed,
sitting, or even while suspended, the muscular strength is found to be
good." Other cases are associated with spasm or ataxia ; thus there may
be movements which stiffen the legs and give to the gait a somewhat spas-
tic character. In other instances there are sudden flexions of the legs, or
even of the arms, or a saltatory, spring-like spasm. In a majority of the
cases it is a manifestation of a neurosis allied to hysteria.
The cases, as a rule, recover, particularly in young persons. Relapses
are not uncommon. The rest treatment and static electricity should be
employed.
Y. YASO-MOTOE AND TKOPHIC DISOEDEES.
I. RAYNAUD'S DISEASE.
Definition. — A vascular disorder, probably dependent upon vaso-
motor influences, characterized by three grades of intensity : (a) Local
syncope, (b) local asphyxia, and (6') local or symmetrical gangrene.
Local Syncope. — This condition is seen most frequently in the extrem-
ities, producing the condition known as dead fingers or dead toes. It is
analogous to that produced by great cold. The entire hand may be af-
fected with the fingers ; more commonly only one or more of the fingers.
This feature of the disease rarely occurs alone, but is generally associated
with local asphyxia. The common sequence is as follows : On exposure to
slight cold or in consequence of some emotional disturbance the fingers
become white and cold, or both fingers and toes are affected. The pallor
may continue for an indefinite time, though usually not more than an
hour or so ; then gradually a reaction follows and the fingers get burning
hot and red. This does not necessarily occur in all the fingers together ;
one finger may be as white as marble, while the adjacent ones are of
a deep red or plum color.
Local Asphyxia. — Chilblains form the mildest grade of this condition.
It usually follows the local syncope, but it may come on independently.
The fingers and toes are oftenest affected, next in order the ears ; more
rarely portions of the skin on the arms and legs. During an attack the
fingers alone, sometimes the hands, also swell and become intensely con-
gested. In the most extreme grade the fingers are perfectly livid, and
the capillary circulation is almost stagnant. The swelling causes stiff-
ness and usually pain, not acute, but due to the tension and distention of
the skin. Sometimes there is marked anaesthesia. Attacks of this sort
98S DISExVSES OF THE NERVOUS SYSTEM.
may recur for years, and be brought on by the slightest exposure to cold or
in consequence of disturbances, either mental or, in some instances, gastric.
Apart from this unpleasant symptom the general health may be very good.
The attacks may recur only at long intervals or during the winter time.
Local or Symmetrical Gangrene. — The mildest grade of this condition
follows the local asphyxia, in the chronic cases of which small necrotic
areas are sometimes seen at the tips of the fingers. Sometimes the pads
of the fingers and of the toes are quite cicatricial from repeated slight
losses of this kind. So also when the ears are affected there may be super-
ficial loss of substance at the edge. The severer cases, which terminate
in extensive gangrene, are fortunately rare.
In an attack the local asphyxia persists in the fingers. The terminal
phalanges, or perhaps only one finger, become black, cold, and insensi-
ble. The skin begins to necrose and superficial gangrenous blebs appear.
Gradually a line of demarkation shows itself and a portion of one or more
of the fingers sloughs away. The resulting loss of substance is much less
than the appearance of the hand or foot would indicate, and a condition
which looks as if the patient would lose all the fingers or half of a foot
may result perhaps in only a slight superficial loss in the phalanges. In
severer cases the greater portion of a finger or the tip of the nose may be
lost. Occasionally the disease is not confined to the extremities, but affects
symmetrical patches on the limbs or trunk, and may pass on to rapid gan-
grene. These severe types of eases occur particularly in young children,
and death may result within three or four days. The attacks are usually
very painful, and the motion of the part is much impaired. In some
cases numbness and tingling persist for a long time.
There are remarkable concomitant symptoms in Eaynaud's disease to
which a good deal of attention has been paid of late years. Haemoglobi-
nuria may develop during an attack, or may take the place of an outbreak.
In such instances the affection is usually brought on by cold weather.
In a case reported by H. M. Thomas from my clinic, Raynaud's dis-
ease occurred for three successive winters and always in association with
haemoglobinuria. The attacks were sometimes preceded by a chill. Sev-
eral cases of the kind are found in Barlow's appendix to his translation of
Raynaud's paper for the New Sydenham Society. The onset with a chill,
as in the case just mentioned, has doubtless given rise to the idea that the
disease is in some way associated with ague. Cerebral symptoms, particu-
larly mental torpor and transient loss of consciousness, have also been
noticed in some cases. The case just mentioned with haemoglobinuria
liad epilepsy with tlie attacks. Exposure on a cold day would bring on
an epileptic seizure with the local asphyxia and bloody urine. Occasion-
ally joint affections develop, particularly anchylosis and thickening of the
l)halangeal articulations. Southey has reported a case in which mania de-
veloped, and Barlow an instance in which the woman had delusions.
Peripheral neuritis has been found in several cases.
ANGIO-NEUROTIC (EDEMA. 989
The paUiology of this remtirkiiblo disease is still obscure. Kaynaud
suggested that the local syncope was produced by contraction of the ves-
sels, which seems likely. The asphyxia is dependent upon dilatation of
the capillaries and small veins, probably with the persistence of some de-
gree of spasm of the smaller arteries. There are two totally different forms
of congestion, which may be shown in adjacent fingers ; one may be
swollen, of a vivid red color, extremely hot, the capillaries and all the ves-
sels fully distended, and the anaemia produced by pressure may be instanta-
neously obliterated ; the adjacent finger may be equally awollen, abso-
lutely cyanotic, stone cold, and the anaemia produced by pressure takes a
long time to disappear. In the latter case the arterioles are probably still
in a condition of spasm.
Treatment. — In many cases the attacks recur for years uninfluenced
by treatment. Mild attacks require no treatment. In the severer forms
of local asphyxia, if in the feet, the patient should be kept in bed with
the legs elevated. The toes should be wrapped in cotton-wool. The pain
is often very intense and may require morphia. Carefully applied, sys-
tematic massage of the extremities is sometimes of benefit. Galvanism
may be tried. Barlow advises immersing the affected limb in salt water
and placing one electrode over the spine and the other in the water.
II. ANGIO-NEUROTIC CEDEMA.
Definition. — An affection characterized by the occurrence of local
oedematous swellings, more or less limited in extent, and of transient du-
ration. Severe colic is sometimes associated with the outbreak. There is
a marked hereditary disposition in the disease. The affection has been
specially studied by Quincke, Jamieson, J. E. Graham, and Matas.
Symptoms. — The oedema appears suddenly and is usually circum-
scribed. It may appear in the face ; the eyelid is a common situation ; or
it may involve the lips or cheek. The backs of the hands, the legs, or
the throat may be attacked. Usually the condition is transient, associated
perhaps with slight gastro-intestinal distress, and the affection is of little
moment. There may be a remarkable periodicity in the outbreak of the
oedema. In Matas's case this periodicity was very striking ; the attack
came on every day at eleven or twelve o'clock. The disease may be hered-
itary through many generations. In the family whose history I reported,
five generations had been affected, including twenty-two members. The
swellings appear in various parts ; only rarely are they constant in one local-
ity. The hands, face, and genitalia are the parts most frequently affected.
Itching, heat, redness, or, in some instances, urticaria may precede the
outbreak. Sudden oedema of the larynx may prove fatal. Two mem-
bers of the family just referred to died of this complication. In one
member of this family, whom I saw repeatedly in attacks, the swell-
990 DISEASES OF THE NERVOUS SYSTEM.
ings came on in different parts ; for example, the under lip would be
swollen to such a degree that the mouth could not be opened. The hands
enlarge suddenly, so that the iingers cannot be bent. The attacks recur
every three or four weeks. Accompanying them are usually gastro-
intestinal attacks, severe colic, pain, nausea, and sometimes vomiting.
The colic is of great intensity and usually requires morphia. Arthritis
apparently does not occur.
The disease has affinities with urticaria, the giant form of which is
probably the same disease. There is a form of severe purpura, often with
urticarial manifestations, which is also associated with marked gastro-
intestinal crises. Quincke regards the condition as a vaso-motor neurosis,
under the influence of which the permeability of the vessels is suddenly
increased.
The treatment is very unsatisfactory. In the cases associated with
anoemia and general nervousness, tonics, particularly large doses of strych-
nia, do good ; but too often the disease resists all treatment.
III. FACIAL HEMI-ATROPHY.
An affection characterized by progressive wasting of the bones and
soft tissues of one side of the face. The atrophy begins, as a rule, in
childhood, but in a few cases has not come on until middle age. It begins
diffusely, but in some instances has started at one spot on the skin and has
gradually spread, involving at first the subcutaneous tissues, then the
muscles and the bones, more particularly the upper jaw. The wasting is
sharply limited at the middle line, and the appearance of the patient is
very remarkable, the face looking as if made up of two halves from differ-
ent persons. There is usually change in the color of the skin and the
hair falls. Owing to the wasting of the alveolar processes the teeth be-
come loose and ultimately fall out. The wasting involves the tissues of
the orbit, and the eye on the affected side is sunken. In a majority of the
cases the atrophy has been confined to one side of the face, but there are
instances on record in which the disease was bilateral, and a few cases in
wliich there were areas of atrophy on the back and on the arm of the
same side. The disease is rare. Sachs has collected 97 cases from the
literature.
Two autopsies have been made. In Mendel's case there was the terminal
stage of an interstitial neuritis in all the branches of the trigeminus,
from its origin to the periphery, most marked in the superior maxillary
branch.
In Ilomen's case, which came on rapidly and scarcely belongs to the
typical form of the disease, a tumor was found pressing upon the Gas-
serian ganglion and the trigeminus nerve.
The disease is recognized at a glance. The facial asymmetry asso-
ACROMEGALIA. 991
ciated with congenital wryneck must not bo confounded with progressive
facial hemi-atrophy. The precise nature of the disease is still doubtful.
IV. ACROMEGALIA.
Definition. — A dystrophy characterized by abnormal processes of
growth, chiefly in the bones of the face and extremities.
The term was introduced by Marie, and signifies large extremities.
Etiology. — Nothing definite is known concerning the cause of the
disease. It occurs rather more frequently in women. Of the 38 cases
analyzed in the monograph of Souza-Leite, 16 were in men and 22 in
women. The disease usually begins about the twenty-fifth year, though
in some instances as late as the fortieth. Rheumatism, syphilis, and the
specific fevers have preceded the development of the disease, but probably
have no special connection with it. In this country five or six cases have
been reported, two by J. E. Graham, of Toronto.
Symptoms. — In a well-marked case the disease presents most char-
acteristic features. The hands and feet are greatly enlarged, but are not
deformed, and can be used freely. The hypertrophy is general, involving
all the tissues, and gives a curious spade-like character to the hands. The
wrists may be enlarged, but the arms are rarely affected. The feet are
involved like the hands and are uniformly enlarged. The big toe may be
much larger in proportion. The nails are usually broad and large. The
head increases in volume, but not as much in proportion as the face, which
becomes much elongated and enlarged in consequence of the increase in
the size of the superior and inferior maxillary bones. The latter in par-
ticular increases greatly in size, and often projects below the upper jaw.
The alveolar processes are widened and the teeth separated. The soft
parts also increase in size, and the nostrils are large and broad. The eye-
lids are sometimes greatly thickened, and the ears enormously hypertro-
phied. The tongue in some instances becomes greatly enlarged. Late in
the disease the spine may be affected and the back bowed — kyphosis. The
bones of the thorax may slowly and progressively enlarge. With this
gradual increase in size the skin of the hands and face may appear normal.
Sometimes it is slightly altered in color, coarse, or flabby, but it has not
the dry, harsh appearance of the skin in myxoedema. The muscles are
sometimes wasted. Changes in the thyroid have been found, but are
not constant. The gland has been normal in some, hypertrophied in
others, and in a third group of cases enlarged. Erb, who has made
an elaborate study of the disease, has noticed an area of dulness over
the manubrium sterni, which he thought possibly due to the persist-
ence or enlargement of the thymus. Headache is not uncommon. Men-
strual disturbance may occur early, and there may be suppression. In
some instances vision has been involved, owing to a gradual atrophy of
992 DISEASES OF THE NERVOUS SYSTEM.
the oj^tic nerve. The disease may persist for fifteen, twenty, or more
years.
The pathological anatomy has been studied in a few cases. In addi-
tion to enlargement of the bones, which is a true hypertrophy, enormous
enhirgement of the hypophysis (pituitary body) has been found, and some
have regarded the disease as associated in some way with this. Less con-
stant have been the changes in the thymus and in the thjrroid. In some
instances the peripheral nerves have been involved. The most exhaustive
anatomical study made as yet is that published by Arnold, of Heidelberg,
on the case which was described clinically by Friedreich and Erb.
As stated, the true nature of the disease is unknown. Marie regards
it as a systemic dystrophy, analogous to myxoedema and possibly due to
the morbid condition of the pituitary body, just as myxoedema is associated
with disease of the thyroid.
Diagnosis. — The disease must be carefully separated from the osteitis
deformans of Paget, in which the shafts of the long bones are chiefly in-
volved, and in the head the bones of the cranium, but not those of the face.
Marie states that in Paget's disease the face is triangular with the base
upward ; in acromegalia it is ovoid, or egg-shaped, with the large end
downward ; while in myxoedema it is round and full-moon shaped. The
disease must not be confounded with the instances of congenital or pro-
gressive hypertrophy of a single member, as of the leg or arm, the so-
called giant growth, in which the various proportions are maintained.
Lastly, Marie has separated from acromegalia a group of cases char-
acterized by hypertrophy of the bones of the extremities and of the shafts,
producing great disability. The spine is also affected and curvature takes
place. The fingers are characteristic. The terminal phalanges become
bulbous, enlarged, and the nails are curved, which gives the appearance of
the so-called Hippocratic finger, a very different condition indeed from the
flattened terminal phalanges of acromegalia. Etiologically, Marie regards
this form as associated in some way with pulmonary troubles. Thus, for
instance, two of the patients had purulent pleurisy, the cases of Ewald
and of Saundby had new growths in the lungs, and others presented
chronic bronchitis. Marie, therefore, terms this form osteo-arthropathie
pneumique. It is doubtful, however, as Arnold states in his exhaustive
study of Friedreich's case, whether this form can really be separated from
acromegalia.
The treatment does not appear to have any influence upon the progress
of the disease.
Here may be mentioned a remarkable dystrophy, met with so far only
in women, known as sclerodactyle, in which there are symmetrical involve-
ments of the fingers, which become deformed, shortened, and atrophied.
The skin becomes thickened, of a waxy color, and is sometimes pigmented,
l^ullnr* and ulcerations have been met with in some instances, and a great
deformity of the nails. The disease has usually followed exposure, and the
SCLERODERMA. 993
patients are much worse during the winter and are curiously sensitive to
cold. There may be changes in the skin of the feet, but tlie deformity
similar to that which occurs in the hand has not been noted. 8ome of the
cases have presented in addition diffuse sclerodermatous changes of the
skin of other parts. An admirable description of the disease has been
given by Gordinier.*
V. SCLERODERMA.
Definition. — A condition of localized or diiiuse induration of the
skin.
Two forms are recognized, the localized or circumscribed, w^hich cor-
responds to the keloid of Addison and to morphea, and the diffuse, in
which large areas are involved.
In the circicmscrihed form there are patches, ranging from a few cen-
timetres in diameter to the size of the hand or larger, in which the skin
has a waxy or dead-white appearance and to the touch is brawny, hard,
and inelastic. Sometimes there is a preliminary hypersemia of the skin,
and subsequently there are changes in color, either areas of pigmentation
or of complete atrophy of the pigment — leucoderma. The sensory changes
are rarely marked. The secretion of sweat is diminished or entirely abol-
ished. The disease is more common in women than in men, and is situ-
ated most frequently about the breasts and neck, sometimes in the course
of the nerves. The patches may develop with great rapidity, and may per-
sist for months or years ; sometimes they disappear in a few weeks.
The diffuse form^ though less common, is more serious. It develops
first in the extremities or in the face, and the patient notices that the skin
is unusually hard and firm, or that there is a sense of stiffness or tension
in making accustomed movements. Gradually a diffuse, brawny indura-
tion develops and the skin becomes firm and hard, and so united to the
subcutaneous tissues that it cannot be picked up or pinched. The skin
may look natural, but more commonly is glossy, drier than normal, and
unusually smooth. Of 44 cases, in 24 the first appearances were on the
arms, in 7 on the legs, in 1 on both, in 10 on the face and neck, and in 2
on the trunk (Dinkier). The disease may gradually extend and involve
the skin of an entire limb ; in rare cases, it becomes universal, the face
is expressionless, the lips cannot be moved, mastication is impossible, and
it becomes extremely difficult to feed the patient. The hands become
fixed, the fingers immobile, on account of the extreme induration of the
skin over the joints. The disease is chronic, lasting for many months or
many years. There are instances on record of its persistence for more
than twenty years. Recovery may occur, or the disease may be arrested.
* American Journal of the Medical Sciences, January, 1889.
99i DISEASES OF THE NERVOUS SYSTEM.
The patients are apt to succumb to pulmonary complaints or to nephritis.
Rheumatic troubles have been noticed in some instances ; in others, endo-
carditis. The patliology of the disease is unknown. It is usually regarded
as a tropho-neurosis, probably dependent upon changes in the arteries of
the skin leading to connective-tissue overgrowth.
The patients require to be warmly clad and to be guarded against
exposure, as they are particularly sensitive to changes in the weather.
Frictions with oil, and galvanism are recommended.
AINHUM.
Here a brief reference may be made to the remarkable trophic lesion
described by Da Silva Lima, which is met with in negroes in Brazil, Africa,
India, and occasionally in the Southern States. It is confined to the toes,
usually the little toe, and begins as a furrow on the line of the digito-
plantar fold. This gradually deepens, the end of the toe enlarges, and,
usually without inflammation or pain, the toe falls off. The process may
last some years. Cases have been reported in this country by Hornaday,
Pittman, F. J. Shepherd, and Morrison.
SECTION IX.
DISEASES OF THE MUSCLES.
I. MYOSITIS.
Definition. — Inflammation of the voluntary muscles.
A primary myositis occurs as an acute or subacute affection, and is
probably dependent on some unknown infectious agent. Several charac-
teristic cases have been described of late years. The case of E. Wagner
may be taken as a t}^ical example. A tuberculous but well-built woman
entered the hospital, complaining of stiffness in the shoulders and a
slight oedema of the back of the hands and forearms. There was paraes-
thesia, the arms became swollen, the skin tense, and the muscles felt
doughy. Gradually the thighs became affected. The disease lasted about
three months. The post-mortem showed slight pulmonary tuberculosis ;
all the muscles except the glutei, the calf, and abdominal muscles were
stiff and firm, but fragile, and there were serous infiltration, great pro-
liferation of the interstitial tissue, and fatty degeneration. Similar cases
have been reported by Unverricht, Hepp, and Jacoby of New York. In
the case reported by Jacoby the muscles were firm, hard, and tender, and
there was slight oedema of the skin The duration of the cases is usually
from one to three months, though there are instances in which it has been
longer The swelling and tenderness of the muscles, the oedema, and the
pain naturally Guggest trichinosis, and indeed Hepp speaks of it as a
pseudo-trichinosis. The nature of the disease is unknown. Senator's case
presented marked disorders of sensation, and there is a question whether
the peripheral nerves are not involved with the muscles. Wagner suggests
that some of these cases were examples of acute progressive muscular atro-
phy. The separation from trichinosis can be made only by removing a
portion of the muscle. There are septic cases in which a diffuse, purulent
infiltration of the muscles of different regions occurs. Instances have
been reported in which this has been described as the primary affection,
the condition of the muscles even passing on to gangrene.
A remarkable affection is myositis ossificans progressiva^ in which
portions of the muscles undergo a progressive calcification.
63
996 DISEASES OF THE MUSCLES.
II. IDIOPATHIC MUSCULAR ATROPHY
{Primary Muscular Dystrophy — Erh).
Definition. — Muscular wasting, with or without an initial hyper-
trophy, beginning in various groups of muscles, usually progressive in
character, and dependent on primary changes in the muscles themselves.
A marked hereditary disposition is met with in the disease.
Before considering the primary muscular atrophies it may be well to
summarize briefly the chief conditions under which muscular atrophy oc-
curs. These are :
(1) Acute or chronic lesions of the nuclei of the motor path, which
may be {a) cortical, as a direct result of a cerebral lesion ; {h) medul-
lary, as in chronic bulbar paralysis ; {c) spinal, either acute, as in polio-
myelitis of children, or chronic, as in the progressive muscular atrophy of
the simple or of the spastic type.
(2) Neuritic muscular atrophy, following a local neuritis due to trauma,
a multiple neuritis due to alcohol, lead, and the infectious diseases. In
this same category probably may be placed the muscular atrophies associated
with joint-disease, the progressive hemi-atrophy of the face, and the atro-
phy sometimes found in cases of hysteria.
(3) Conditions of the muscles themselves — primary muscular atrophy.
Etiology. — The most important factor is heredity. Many members
of the same family may be attacked through several generations. Males,
as a rule, are more frequently affected than females. The disease is usu-
ally transmitted through the mother, though she may not herself be the
subject. As many as twenty or thirty cases have been described in five
generations. Isolated cases, however, are not uncommon. The disease
usually sets in before puberty, but may be as late as the twentieth or
twenty-fifth year, or in some instances even later. No etiological factors
of any moment are known other than heredity.
Clinical Forms. — Two chief types may be recognized : (1) With
primary hypertrophy, the pseudo-hypertrophic muscular paralysis; and
(2) with primary atrophy.
Pseudo-hypertrophic Muscular Paralysis. — The first symptom no-
ticed is, as a rule, clumsiness in the movements of the child, and on ex-
amination certain muscles or groups of muscles seem to be enlarged, par-
ticularly those of the calves. The extensors of the leg, the glutei, the
lumbar muscles, the deltoid, triceps, and infraspinatus, are the next most
frequently involved, and may stand out with great prominence. The muscles
of the neck, face, and forearm rarely suffer. Sometimes only a portion of
a muscle is involved. With this hypertrophy of some muscles there is
wasting of others, particularly the lower portion of the pectorals and the
latissimus dorsi. The attitude when standing is very characteristic. The
legs are far apart, the shoulders thrown back, the spine is greatly curved,
and the abdomen protrudes. The gait is waddling and awkward. In
IDIOPATHIC MUSCULAR ATROPHY. 997
getting up from, the floor the position assumed, as so well known now
through Gowers's figures, is pathognomonic. The patient first turns over
in the all-fours position and raises the trunk with his arms ; the hands arc
then moved along the ground until the knees are reached ; then with one
hand upon a knee he lifts himself up, grasps the other knee, and gradu-
ally pushes himself into the erect posture, as it has been expressed, by
climbing up his legs. The striking contrast between the feebleness of
the child and the powerful-looking pseudo-hypertrophic muscles is very
characteristic.
The course of the disease is slow, but progressive. Wasting proceeds
and finally all traces of the enlarged condition of the muscles disappears.
At this late period distortions and contractions are common.
Primary Atroj^hic Form. — Here, too, there is the same marked tend-
ency to involvement of different members of a family. Five or six dif-
ferent types have been described, but it seems more rational to group
them together under the designation of idiopathic muscular atrophy. In
all of the cases the atrophy begins, as a rule, before the twentieth year.
According to the site of the primary atrophy different forms have been
described. In the juvenile type of Erb the affection begins about the
fifteenth or the twentieth year and involves the muscles of the upper
arm and shoulder and the gluteal and thigh muscles. In the facio-
scapulo-humeral t\^e of Landouzy and Dejerine the muscles of the face
are early involved with those of scapulo-humeral groups. This form oc-
curs usually in families, and the onset may be dela3^ed until the twenti-
eth or thirtieth year. Leyden describes an hereditary form^ beginning in
the lower extremities and back, which maj^ be associated with hypertrophy
of the calves. Another type has been described by Charcot and Tooth —
the peroneal form ; but there is still some doubt whether this is not in
reality a myelopathy and more closely related to chronic polio-myelitis
anterior. In this form the atrophy begins in the muscles of the legs,
usually in the extensors of the great toe, and afterward in the common
extensors and the peroneal groups. The cases usually begin early, and
the heredity through the mother has been traced in several remarkable
series, particularly that of Herringham's. Fibrillary contractions and
the reaction of degeneration are present. Nerve degeneration has been
found in the peripheral parts, and ascending degeneration of the columns
of (;oll.
Morbid Anatomy. — The spinal cord and peripheral nerves have
been found normal in cases of pseudo-hypertrophic muscular paralysis and
in the forms of idiopathic muscular atrophy. The muscles in the pseudo-
hypertrophic condition present great variations in the size of the muscle
fibres, some of which may be hypertrophiod and others wasted. In the
early stage the hypertrophy of the fibres may be very pronounced and the
nuclei of the sarcolemma are greatly increased. In some instances, too,
the fibres have been fissured longitudinally. At a later stage the muscular
998 DISEASES OF THE MUSCLES.
fibres are wasted and largely replaced by connective tissue and fat. In
the primary atrophic form wasting of the fibres, increase in the interstitial
tissue, and the development of fat are the most marked features. Except
in the peroneal type, about which there is still doubt, no affection of the
nerves or cord has been determined.
Diagnosis. — The primary myopathies can usually be readily distin-
guished from the cerebral, myelopathic, and neuritic forms.
(a) In the cerebral atrophy loss of power usually precedes the atrophy,
which is either of a monoplegic or hemiplegic type.
(b) In the myelopathic or spinal muscular atrophy the distinctions
are clearly marked. Polio-myelitis anterior chronica begins in the small
muscles of the hand, a situation rarely if ever affected by the primary
myopathies, which involve first those of the calves, the trunk, the face, or
the shoulder-girdle. In the myelopathic atrophy the reaction of degenera-
tion is present and fibrillary twitchings occur in both the atrophied and
non-atrophied muscles. In many cases in addition to the wasting in the
arms there is a spastic condition in the legs and increase in the reflexes.
The myelopathic atrophies come on late in life ; the myopathic forms de-
velop, as a rule, early. In the primary muscular atrophies heredity plays
an important role^ which in the myelopathic is quite subsidiary.
(c) In the neuritic muscular atrophies, whether due to lead or to
trauma, the general characters and the mode of onset are distinctive. In
the cases of multiple neuritis seen for the first time at a period when the
wasting is marked there is often difficulty, but the absence of family
history and the distribution are important features. Moreover, the paral-
ysis is out of proportion to the atrophy. Sensory symptoms may be
present, and in the cases in which the legs are chiefly involved there is usu-
ally the steppage gait so characteristic of peripheral neuritis.
The outlook in the primary myopathies is bad. The wasting pro-
gresses uniformly, uninfluenced by treatment. Erb holds that by elec-
tricity and massage the progress is occasionally arrested. The general
health should be carefully looked after, moderate exercise allowed, fric-
tions with oil applied to the muscles, and when the patient becomes
bedfast, as is inevitable sooner or later, care should be taken to prevent
contractures in awkward positions.
III. THOMSEN'S DISEASE; MYOTONIA CONGENITA.
Definition. — An hereditary disease ^characterized by tonic cramp of
the muscles on attempting voluntary movements. The disease received its
name from the physician who first described it, in whose family it has
existed for five generations.
Etiology. — All the typical cases have occurred in family groups ;
a few isolated instances have been described in which similar symptoms
PARAMYOCLONUS MULTIPLEX. 999
have been present. The disease is rare in this country and in England ;
it seems more common in Germany and in Scandinavia.
Symptoms. — The disease comes on in childhood. It is noticed that
on account of the stiffness the children are not able to take part in ordi-
nary games. The peculiarity is noticed only during voluntary movements.
The contraction which the patient wills is slowly accomplished ; the
relaxation which the patient wills is also slow. The contraction often per-
sists for a little time after he has dropped an object which he has picked
up. In walking, the start is difficult ; one leg is put forward slowly, it
halts from stiffness for a second or two, and then after a few steps the
legs become limber and he walks without any difficulty. The muscles of
the arms and legs are those usually implicated ; rarely facial, ocular, or
laryngeal muscles. Emotion and cold aggravate the condition. In some
instances there is mental weakness. The sensation and the reflexes are
normal. The condition of the muscles is interesting. The patients ap-
pear and are muscular, and there is sometimes a definite hypertrophy of
the muscles. The force is scarcely proportionate to the size. Erb has
described a characteristic reaction of the nerve and muscle to the elec-
trical currents — the so-called myotonic reaction, the chief feature of which
is that normally the contractions caused by either current attain their
maximum slowly and relax slowly, and vermicular, wave-like contractions
pass from the cathode to the anode.
The disease is incurable, but it may be arrested temporarity. The
nature of the affection is unknown. There is an extraordinary increase in
the size of the voluntary fibres. According to Hale White,* who has
recently treated the subject in an exhaustive and critical manner, the
fibres may be more than double the width of those of the normal muscles.
The nuclei and the interstitial tissue may be increased and some of the
fibres contain vacuoles. Xo post-mortem has been made. No treatment
for the condition is known.
IV. PARAMYOCLONUS MULTIPLEX.
An affection, described by Friedrich, characterized by clonic contrac-
tions, chiefly of the muscles of the extremities, occurring either constantly
or in paroxysms.
The cases have usually been in males and the disease has followed
emotional disturbance, fright, or straining. The contractions are usually
bilateral and may vary from fifty to one hundred and fifty in the minute.
Occasionally tonic spasms occur. It is not accompanied by any sensory
or motor disturbances. In the intervals between the attacks there may be
tremors of the muscles. In the severe spasms the movements may be very
Guy's Hospital Reports, 1889.
1000 DISEASES OF THE MUSCLES.
violent ; the body is tossed about, and it is sometimes difficult to keep the
patient in bed. In a case which I saw at the Bicetre the patient was per-
fectly quiet so long as his legs were tied down with a sheet, but as soon as
this was removed the clonic spasms occurred in the legs and muscles of
the back and tossed the body about in the bed from side to side. The
patient uttered a curious expiratory grunt. The nature of the disease is
unknown.
SECTION X.
THE INTOXICATIONS, SUN-STEOKE,
OBESITY.
I. ALCOHOLISM.
(1) Acute Alcoholism. — When a large quantity of alcohol is taken, its
influence on the nervous system is manifested in muscular incoordina-
tion, mental disturbance, and, finally, narcosis. The individual presents a
flushed, sometimes slightly cyanosed face, a full pulse, with deep but rarely
stertorous respirations. The pupils are dilated. The temperature is fre-
quently below normal, particularly if the patient has been exposed to
cold. Perhaps the lowest reported temperatures have been in cases of this
sort. An instance is on record in which the patient on admission to hos-
pital had a temperature of 24° C. (ca. 75° F.), and ten hours later the
temperature had not risen to 91°. The unconsciousness is rarely so deep
that the patient cannot be roused to some extent, and in reply to questions
he mutters incoherently. Muscular twitchings may occur, but rarely con-
vulsions. The breath has a heavy alcoholic odor.
The diagnosis is not difficult, yet mistakes are frequently made. Per-
sons are sometimes brought to hospital by the police supposed to be drunk
when in reality they are dying from apoplexy. Too great care cannot be
exercised, and the patient should receive the benefit of the doubt. In
some instances the mistake has arisen from the fact that a person who has
been drinking heavily has been stricken with apoplexy. In this condition
the coma is usually deeper, stertor is present, and there may be evidence of
hemiplegia in the greater flaccidity of the limbs on one side. The subject
has already been considered in the section upon uraemic coma.
(2) Chronic Alcoholism. — In moderation, wine, beer, and spirits may
be taken throughout a long life without impairing the general health.
According to Payne, the poisonous effects of alcohol are manifested (1)
as a functional poison, as in acute narcosis ; (2) as a tissue poison, in which
its effects are seen on the parenchymatous elements, particularly epithe-
lium and nerve, producing a slow degeneration, and on the blood-vessels,
causing thickening and ultimately fibroid changes; and (3) as a checker
1002 THE INTOXICATIONS, SUN-STROKE, OBESITY.
of tissue oxidation, since the alcohol is consumed in place of the fat. This
leads to fatty changes and sometimes to a condition of general steatosis.
The chief effects of chronic alcohol poisoning may be thus summa-
rized :
Nervous System. — Functional disturbance is common. — Unsteadiness
of the muscles in performing any action is a constant feature. The
tremor is best seen in the hands and in the tongue. The mental processes
may be dull, particularly in the early morning hours, and the patient
is unable to transact any business until he has had his accustomed stimu-
lant. Irritability of temper, forgetfulness, and a change in the moral
character of the individual gradually come on. The judgment is seri-
ously impaired, the will enfeebled, and in the final stages dementia may
supervene. The relation of chronic alcoholism to insanity has been much
discussed. According to Savage, of 4,000 patients admitted to the Beth-
lehem Hospital, 133 gave drink as the cause of their insanity. Chronic
alcoholism is believed by many to be one of the special causes of dementia
paralytica, but the opinions of experts on this question are still discordant.
Savage states that not more than seven per cent are caused by alcohol
alone. In many cases it is certainly one of the important elements in the
strain which leads to this breakdown.
No characteristic changes are found in the nervous system. Haemor-
rhagic pachymeningitis is not very uncommon. Opacity and thickening
of the pia-arachnoid membranes, with more or less wasting of the convo-
lutions, generally occur. These are in no way peculiar to chronic alcohol-
ism, but are found in old persons and in chronic wasting diseases. In the
very protracted cases there may be chronic encephalo-meningitis with ad-
hesions of the membranes. By far the most striking effect of alcohol on
the nervous system is the production of the alcoholic neuritis, which has
already been considered.
Digestive System. — Catarrh of the stomach is the most common symp-
tom. The toper has a furred tongue, heavy breath, and in the morning a
sensation of sinking at the stomach until he has his dram. The appetite
is usually impaired and the bowels are constipated. These features are
associated with a chronic catarrh of the stomach.
Alcohol produces definite changes on the liver, leading to the various
forms of cirrhosis already described. The effect is probably a primary
degenerative change in the liver-cells, although many good observers still
hold that the poison acts first upon the connective-tissue elements. It is
probable that a special vulnerability of the liver-cells is necessary in the
etiology of alcoholic cirrhosis. There are cases in which comparatively
moderate drinking for a few years has been followed by cirrhosis ; on the
other hand, the livers of persons who liave been steady drinkers for thirty
or forty years may show only a moderate grade of sclerosis. With the gas-
tric and hepatic disorders the facies often becomes very characteristic. The
venules of the cheeks and nose are dilated ; the latter becomes enlarged,
ALCOHOLISM. 1003
red, and may present tlic condition known as acne rosacea. TIic eyes are
watery, the conjunctivae liyperaemic and sometimes bile-tinged.
Kidneys. — The influence of chronic alcoholism upon these organs is
by no means so marked. According to Dickinson the total of renal dis-
ease is not greater in the drinking class, and he holds that the effect of
alcohol on the kidneys has been much overrated. Formad has directed at-
tention to the fact that in a large proportion of chronic alcoholics the kid-
neys are increased in size. The Guy's Hospital statistics support this
statement, and Pitt notes that in forty-three per cent of the bodies of hard
drinkers the kidneys were hypertrophied without showing morbid change.
The typical granular kidney seems to result indirectly from alcohol
through the arterial changes.
It was formerly thought that alcohol was in some way antagonistic to
tuberculous disease, but the observations of late years indicate clearly that
the reverse is the case and that chronic drinkers are much more liable to both
acute and pulmonary tuberculosis. It is probably altogether a question of
altered tissue-soil, the alcohol lowering the vitality and enabling the bacilli
more readily to develop and grow.
(3) Delirium Tremens {mania apotu) is really only an incident in the
history of chronic alcoholism, and results from the long-continued action
of the poison on the brain. The condition was first accurately described
early in this century by Sutton, of Greenwich, who had numerous oppor-
tunities for studying the different forms among the sailors. One of the
most thorough and careful studies of the disease was made by Ware, of
Boston. A spree in a temperate person, no matter how prolonged, is rare-
ly if ever followed by delirium tremens ; but in the case of an habitual
drinker a temporary excess is apt to bring on an attack. It sometimes
develops in consequence of the sudden withdrawal of the alcohol. There
are circumstances which in a heavy drinker determine, sometimes with
abruptness, the onset of delirium. Such are an accident, a sudden fright
or shock, and an acute inflammation, particularly pneumonia. At the
outset of the attack the patient is restless and depressed and sleeps badly,
symptoms which cause him to take alcohol more freely. After a day or
two the characteristic delirium sets in. The patient talks constantly and
incoherently ; he is incessantly in motion, and desires to go out and attend
to some imaginary business. Hallucinations of sight and hearing develop.
He sees objects in the room, such as rats, mice, or snakes, and fancies that
they are crawling over his body. The terror inspired by these imaginary
objects is great, and has given the popular name " horrors " to the disease.
The patients need to be watched constantly, for in their delusions they
may jump out of the window or escape. Auditory hallucinations are not
80 common, but the patient may complain of hearing the roar of animals
or the tlireats of imaginary enemies. There is much muscular tremor;
the tongue is covered with a thick white fur, and when protruded is tremu-
lous. The pulse is soft, rapid, and readily compressed. There is usually
1004: THE INTOXICATIONS, SUN-STROKE, OBESITY.
fever, but the temperature rarely registers above 102° or 103°. In fatal
cases it may be higlier. Insomnia is a constant feature. On the third or
fourth day in favorable cases the restlessness abates, the patient sleeps,
and improvement gradually sets in. The tremor persists for some days,
the hallucinations gradually disappear, and the appetite returns. In more
serious cases the insomnia persists, the delirium is incessant, the pulse
becomes more frequent and feeble, the tongue dry, the prostration ex-
treme, and death takes place from gradual heart-failure.
Diagnosis. — The clinical picture of the disease can scarcely be con-
founded with any other. Cases with fever, however, may be mistaken for
meningitis. By far the most common error is to overlook some local dis-
ease, such as pneumonia or erysipelas, or an accident, as a fractured rib,
which in a chronic drinker may precipitate an attack of delirium tremens.
In every instance a careful examination should be made, particularly of
the lungs. It is to be remembered that in the severer forms, particularly
the febrile cases, congestion of the bases of the lungs is by no means un-
common. Another point to be borne in mind is the fact that pneumonia
of the apex is apt to be accompanied by delirium similar to mania a
potu.
Prognosis. — Eecovery takes place in a large proportion of the cases
in private practice. In hospital practice, particularly in the large city
hospitals to which the debilitated patients are taken, the death rate is
higher. Gerhard states that of 1,241 cases admitted to the Philadelphia
Hospital 121 proved fatal. Recurrence is frequent, almost indeed the rule,
if the drinking is kept up.
Treatment. — Acute alcoholism rarely requires any special measures,
as the patient sleeps off the effects of the debauch. In the case of pro-
found alcoholic coma it may be advisable to wash out the stomach, and if
collapse symptoms occur the limbs should be rubbed and hot applications
made to the body. Should convulsions supervene, chloroform may be
carefully administered. In the acute, violent alcoholic mania the hypo-
dermic injection of apomorphia, one eighth or one sixth of a grain, is
usually very effectual, causing nausea and vomiting, and rapid disappear-
ance of the maniacal symptoms.
Chronic alcoholism is a condition very difficult to treat, and once fully
established the habit is rarely abandoned. The most obstinate cases are
are those with marked hereditary tendency. Withdrawal of tlie alcohol is
the first essential. This is most effectually accomplished by placing the
patient in an institution, in which he can be carefully watched during the
trying period of the first week or ten days of abstention. The absence
of temptation in institution life is of special advantage. For the sleep-
lessness the bromides or hyoscine may be employed. Quinine and strych-
nine in tonic doses may be given. Cocaine or the fluid extract of coca
has been recommended as a substitute for alcohol, but it is not of much
service. Prolonged seclusion in a suitable institution is in reality the only
MORPHIA HABIT. 1005
effectual means of cure. When the hereditary tendency is strongly devel-
oped a lapse into the drinking habits is almost inevitable.
In delirium tremens the patient should be confined to bed and care-
fully watched night and day. The danger of escape in these cases is very
great, as the patient imagines himself pursued by enemies or demons.
Flint mentions the case of a man who escaped in his night-clothes and ran
barefooted for fifteen miles on the frozen ground before he was over-
taken. The patient should not be strapped in bed, as this aggravates the
delirium ; sometimes, however, it may be necessary, in which case a sheet
tied across the bed may be sufficient, and this is certainly better than vio-
lent restraint by three or four men. Alcohol should be withdrawn at
once unless the pulse is feeble.
Delirium tremens is a disease which, in a large majority of cases, runs
a course very slightly influenced by medicine. The indications for treat-
ment are to procure sleep and to support the strength. In mild cases half
a drachm of bromide of potassium combined with tincture of capsicum
may be given every three hours. Chloral is often of great service, and may
be given without hesitation unless the heart's action is feeble. Good re-
sults sometimes follow the hypodermic use of hyoscine, one one-hundredth
of a grain. Opium must be used cautiously. A special merit of Ware's
work was the demonstration that on a rational or expectant plan of treat-
ment the percentage of recovery was greater than with the indiscriminate
use of sedatives, which had been in vogue for many years. When opium is
indicated it should be given as morphia, hypodermically. The effect
should be carefully watched, and if after three or four quarter-grain doses
have been given the patient is still restless and excited, it is best not to
push it farther. When fever is present the tranquillizing effects of a cold
douche or cold bath may be tried, or the cold pack. The large doses of
digitalis formerly employed are not advisable.
Careful feeding is the most important element in the treatment of
these cases. Milk and concentrated broths should be given at stated
intervals. If the pulse becomes rapid and shows signs of flagging alcohol
may be given in combination with the aromatic spirits of ammonia.
II. MORPHIA HABIT {MorpMomania ; Morphinism).
This habit arises from the constant use of morphia — taken at first, as a
rule, for the purpose of allaying pain. The craving is gradually engen-
dered, and the habit in this way acquired. The injurious effects vary
very much, and in the East, where opium-smoking is as common as tobacco-
smoking with us, the ill effects are, according to good observers, not so
striking.
The habit is particularly prevalent among women and physicians who
use the hypodermic syringe for the alleviation of pain, as in neuralgia or
1006 THE INTOXICATIONS, SUN-STROKE, OBESITY.
sciatica. The acquisition of the liabit as a pure luxury is rare in this
country.
The symptoms at first are slight, and moderate doses may be taken for
months without serious injury and without disturbance of health. There
are exceptional instances in which for a period of years excessive doses
have been taken without deterioration of the mental or bodily functions.
As a rule, the dose necessary to obtain the desired sensations has gradu-
ally to be increased. xVs the effects wear off the victim experiences sensa-
tions of lassitude and mental depression, accompanied often with slight
nausea and epigastric distress, symptoms which are relieved by another
dose of the drug. The confirmed opium-eater presents a very charac-
teristic appearance. There is a sallowness of the complexion which is
almost pathognomonic, and he becomes emaciated, gray, and prematurely
aged. He is restless, irritable, and unable to remain quiet for any time.
Itching is a common symptom. The sleep is disturbed, the appetite and
digestion are deranged, and except when directly under the influence of
the drug the mental condition is one of depression. Occasionally there
are profuse sweats, which may be preceded by chills. The pupils, except
when under the direct influence of the drug, are dilated, sometimes un-
equal. Persons addicted to morphia are inveterate liars, and no reliance
wdiatever can be placed upon their statements. In many instances this is
not confined to matters relating to the vice. In women the symptoms may
be associated with those of pronounced hysteria or neurasthenia. The
practice may be continued for an indefinite time, usually requiring increase
in the dose until ultimately enormous quantities may be needed to obtain
the desired effect. Finally a condition of asthenia is induced, in which
the victim takes little or no food and dies from the extreme bodily
debility.
The treatment of the morphia habit is extremely diflftcult, and can
rarely be successfully carried out by the general practitioner. Isolation,
systematic feeding, and gradual withdrawal of the drug are the essential
elements. As a rule, the patients must be under control in an institution
and should be in bed for the first ten days. It is best in a majority of
cases to reduce the morphia gradually. The diet should consist of beef-
juices, milk, and egg-white, which should be given at short intervals. The
sufferings of the patients are usually very great, more particularly the ab-
dominal pains, sometimes nausea and vomiting, and the distressing rest-
lessness. Usually within a week or ten days the opium may be entirely
withdrawn. In all cases the pulse should be carefully watched and, if
feeble, stimulants should be given, with the aromatic spirits of ammonia
and diffitalis. For the extreme restlessness a hot bath is serviceable. The
sleeplessness is the most distressing symptom, and various drugs may have
to be resorted to, particularly hyoscine and sulphonal and sometimes, if
the insomnia persists, morphia itself.
It is essential in the treatment of a case to be certain that the patient
LEAD-POISONING 1007
has no means of obtaining morphia. Even under the favorable circum-
stances of seckision in an institution, and constant watching by a night and
a day nurse, I have known a patient to practice deception for a period of
three montlis. After an apparent cure the patients are only too apt to
lapse into the habit.
The condition is one which has become so common, and is so much on
the increase, that physicians should exercise the utmost caution in j)rer
scribing morphia, particularly to female patients. Under no circumstances
whatever should a patient with neuralgia or sciatica be allowed to use the
hypodermic syringe, and it is even safer not to intrust this dangerous
instrument to the hands of the nurse.
III. LEAD-POISONING {Plumbism; Saturnism).
Etiology. — The disease is wide-spread, particularly in lead-workers
and among plumbers, painters, and glaziers. The metal is introduced
into the system in many forms. Miners usually escape, but those engaged
in the smelting of lead-ores are often attacked. Animals in the neighbor-
hood of smelting furnaces have suffered v/ith the disease, and even the
birds that feed on the berries in the neighborhood may be affected. Men
engaged in the white-lead factories are particularly prone to plumbism.
Accidental contamination may come in many ways ; most commonly by
drinking water which has passed through lead pipes or been stored in
lead-lined cisterns. Wines and cider which contain acids quickly become
contaminated in contact with lead. It was the frequency of colic in cer-
tain of the cider districts of Devonshire which gave the name Devonshire
colic, as the frequency of it in Poitou gave the name colica Pictonum.
Among the innumerable sources of accidental contamination may be men-
tioned milk, various sorts of beverages, hair dyes, false teeth, and thread.
A serious outbreak of lead -poisoning, which was investigated by David D.
Stewart, occurred recently in Philadelphia, owing to the disgraceful adul-
teration of a baking-powder with chromate of lead, which was used to give
a yellow tint to the cakes. Lead given medicinally rarely produces poison-
ing.
All ages are attacked, but J. J. Putnam states that children are rela-
tively less liable. The largest number of cases occur between thirty and
forty. According to Oliver, from whose recent Gulstonian lectures I here
quote, females are more susceptible than males. He states that they are
much more quickly brought under its influence, and in a recent epidemic
in which a thousand cases were involved the proportion of females to
males was four to one.
The lead gains entrance to the system through the lungs, the digestive
organs, or the skin. Poisoning may follow the use of cosmetics contain-
ing lead. Through the lungs it is freely absorbed. The chief channel,
1008 THE INTOXICATIONS, SUN-STROKE, OBESITY.
according to Oliver, is the digestive system. It is rapidly eliminated by
the kidneys and skin, and is present in the urine of lead-workers. The
susceptibility is remarkably varied. The symptoms may be manifest with
a month of exposure. On the other hand, Tanquerel (des Planches) met
witli a ease in a man who had been a lead-worker for fifty-two years.
Morbid Anatomy. — Small quantities of lead occur in the body in
health. J. J. Putnam's reports show that of 150 persons not presenting
symptoms of lead-poisoning traces of lead occurred in the urine of 25 per
cent.
In chronic poisoning lead is found in the various organs. The affected
muscles are yellow, fatty, and fibroid. The nerves present the features of
a peripheral degenerative neuritis. The cord and the nerve-roots are, as a
rule, uninvolved. In the primary atrophic form the ganglion cells of the
anterior horns are probably involved. In the acute fatal cases there may
be the most intense entero-colitis.
Clinical Forms. — Acute Poiso7ii7ig. — We do not refer here to the
accidental or suicidal cases, wdiich present vomiting, pain in the abdomen,
and collapse symptoms. In workers in lead there are several manifesta-
tions which follow a short time after exposure and set in acutely. There
may be, in the first place, a rapidly developing anaemia. Acute neuritis has
been described, and convulsions, epilepsy, and a delirium, which may be,
as Stephen Mackenzie has noted, not unlike that produced by alcohol.
There are also cases in which the gastro-intestinal symptoms are most
intense and rapidly prove fatal. There was admitted under my care in the
Philadelphia Hospital a painter, aged fifty, suffering with anasmia and
severe abdominal pain, which had lasted about a week. He had vomiting,
constipation at first, afterward severe diarrhoea and meLnena, with distention
and tenderness of the abdomen. There were albumen and tube-casts in the
urine. The temperature was usually subnormal. Death occurred at the
end of the second week. There was found the most intense entero-colitis
with hfemorrhages and exudation. These acute forms develop more fre-
quently in persons recently exposed, and, according to Mackenzie, are more
frequent in w^inter than in summer.
Chronic polwning presents the following symptoms:
(a) AncBmia, the so-called saturnine cachexia, which may be prof ound.
As a rule, however, the corpuscles do not sink below 50 per cent.
(b) Blue line on gums, which is a valuable indication, but not invari-
ably present. Two lines must be distinguished : one, at the margin be-
tween the gums and teeth, is on, not in the gums, and is readily removed by
rinsing the mouth and cleansing the teeth. The other is the well-known
characteristic blue-black line at the margin of the gum. The color is not
uniform, but being in the papillae of the gums the line is, as seen with a
magnify ing-glass, interrupted. The lead is absorbed and converted in the
tissues into a >)lack sulphide by the action of sulphuretted hydrogen from
the tartar of the teeth. The line may form rapidly after ex2:)osure and
LEAD-POISONING. 1009
disappear within a few weeks, or may persist for many months. Philip-
sou has noted the occurrence of a black line in miners, due to the deposition
of carbon.
The most important symptoms of chronic lead-poisoning are colic,
lead-palsy, and the encephalopatliy. Of these, the colic is the most fre-
quent. Of Tanquerel's cases, there were 1,217 of colic, 101 of paralysis,
and 72 of encephalopathy.
(c) Colic is the most common symptom of chronic lead-poisoning. It
is often preceded by gastric or intestinal symptoms, particularly constipa-
tion. The pain is over the whole abdomen. The colic is usually parox-
ysmal, like true colic, and is relieved by pressure. There is often, in addi-
tion, between the paroxysms a dull, heavy pain. There may be vomiting.
During the attack, as Riegel noted, the pulse is increased in tension and
the heart's action is retarded. The pupils are usually unequal (Oliver).
(d) Lead-palsy. — This is rarely a primary manifestation. The onset
may be acute, subacute, or chronic. It usually develops without fever.
In its distribution it may be partial, limited to a muscle or to certain mus-
cle groups, or generalized, involving in a sliort time the muscles of the
extremities and the trunk. Madame Dejerine-Klumpke recognizes the
following localized forms :
(1) Anti-brachial type, paralysis of the extensors of the fingers and of
the wrist. In this the musculo-spiral nerve is involved, causing the char-
acteristic wrist-drop. The supinator longus usually escapes.
(2) Brachial type, which involves the deltoid, the biceps, the brachi-
alis anticus, and the supinator longus, rarely the pectorals. The atrophy
is of the scapulo-humeral form. It is bilateral, and sometimes follows the
first form, but it may be primary.
(3) The Aran-Duchenne type, in which the small muscles of the hand
and of the thenar and hypothenar eminences are involved. It produces a
paralysis closely resembling that of the early stage of polio-myelitis ante-
rior chronica. The atrophy is marked, and may be the first manifestation
of the lead-palsy. Mobius has shown that this form is particularly de-
veloped in tailors.
(4) The peroneal type. According to Tanquerel, the lower limbs are
involved in the proportion of thirteen to one hundred of the upper limbs.
The lateral peroneal muscles, the extensor communis of the toes, and the
extensor proprius of the big toe are involved, producing the steppage
gait.
(5) Laryngeal form. Adductor paralysis has been noted by Morell
Mackenzie and others in lead-palsy.
Generalized Palsies. — There may be a slow, chronic paralysis, gradu-
ally involving the extremities, beginning with the classical picture of
wrist-drop. More frequently there is a rapid generalization, producing
complete paralysis in all the muscles of the parts in a few days. It may
pursue a course like an ascending paralysis, associated with rapid wasting
1010 THE INTOXICATIONS, SUN-STROKE, OBESITY.
of all four limbs. Such cases, however, are very rare. Death has oc-
curred by involvement of the diaphragm. Oliver reports a case of Philip-
son's in which complete paralysis supervened. Dejerine-Klumpke also
recognizes a febrile form of general paralysis in lead-poisoning, which
may closely resemble the subacute spinal paralysis of Duchenne.
There is also a primary saturnine muscular atrophy in which the
weakness and wasting come on together and develop proportionately. It
is this form, according to Gowers, which most frequently assumes the
Aran-Duchenne type.
The electrical reactions are those of lesions of the lower motor seg-
ment, and have been described under lesions of the nerves. The degen-
erative reaction in its different grades may be present, depending upon the
severity of the disease.
Usually with the onset of the paralysis there are pains in the legs and
joints, the so-called saturnine arthralgias. As a rule, however, sensation
is unaffected and the sensory nerves are not involved.
(e) The cerehral symptoms are numerous. Optic neuritis or neuro-
retinitis may develop. Hysterical symptoms occasionally occur in girls.
Epilepsy is not uncommon, and in fits developing in the adult the possi-
bility of lead-poisoning should always be considered. An acute delirium
may occur with hallucinations. The patients may have trance-like at-
tacks, which follow or alternate with convulsions. A few cases of lead
encephalopathy finally drift into lunatic asylums. Tremor is one of the
commonest manifestations of lead-poisoning.
(/) Arteriosclerosis. — Lead-workers are notoriously subject to arte-
rio-sclerosis with contracted kidneys and hypertrophy of the heart. The
cases usually show distinct gouty deposits, particularly in the big-toe
joint ; but in this country acute gout in lead-workers is rare. According
to Sir William Roberts, the lead favors the precipitation of the crystalline
urates of the tissues. Ralfe has shown that lead diminishes the alkalinity
of the blood, and so lessens the solubility of the uric acid.
Prognosis. — In the minor manifestations of lead-poisoning this is
good. According to Gowers, the outlook is bad in the primary atrophic
form of paralysis. Convulsions are, as a rule, serious, and the mental
symptoms which succeed may be permanent. Occasionally the wrist-drop
persists.
Treatment. — Prophylactic measures should be taken at all lead-
works, but unless employes are careful poisoning is apt to occur even
under the most favorable conditions. Cleanliness of the hands and of the
finger-nails, frequent bathing, and the use of respirators when necessary,
should be insisted upon. When the lead is in the system, the iodide of
potassium should be given in from five- to ten-grain doses three times a
day. For the colic, local applications and, if severe, morphia may be used.
An occasional morning purge of sulphate of magnesia may be given. For
the anaemia iron should be used. In the very acute cases it is well not
ARSENICAL POISONING. 1(1 1 1
to give the iodide, as, according to some writers, the liberation of the lead
which has been deposited in the tissues may increase the severity of the
symptoms. For the local palsies massage and the constant current should
be used.
IV. ARSENICAL POISONING.
Acute poisoning by arsenic is common, particularly by Paris green and
such mixtures as " Kough on Eats," which are used to destroy vermin
and insects. The chief symptoms are intense pain in the stomach, vomit-
ing, and, later, colic, with diarrhoea and tenesmus ; occasionally the symp-
toms are those of collapse. If recovery takes place, paralysis may follow.
The treatment should be similar to that of other irritant poisons — rapid
removal with the stomach pump, the promotion of vomiting, and the use
of milk and eggs. If the poison has been taken in solution, dialyzed
iron may be used in large doses of from six to eight drachms.
Chronic Arsenical Poisoning. — Arsenic is used extensively in the
arts, particularly in the manufacture of colored papers, artificial flowers,
and in many of the fabrics employed as clothing. The glazed green and
red papers used in kindergartens also contain arsenic. It is present also
in many wall-papers and carpets. Much attention has been paid to this
question of late years, as instances of poisoning have been thought to de-
pend upon wall-papers and other household fabrics. According to J. J.
Putnam, the greatest danger is from the dust blown off by currents of air
or detached by the brush. It is thought, too, that possibly some volatile
compound of arsenic may be formed. Arsenic is eliminated in all the
secretions, and has been found in the milk. J. J. Putnam, it should be re-
membered, has shown that it is not uncommon to find traces of arsenic in
the urine of many persons in apparent health. The effects of moderate
quantities of arsenic are not infrequently seen in medical practice. In
chorea and in pernicious anemia, steadily increasing doses are often given
until the patient takes from fifteen to twenty drops of Fowler's solution
three times a day. Flushing and hyperaemia of the skin, puffiness of the
eyelids or above the eyebrows, nausea, vomiting, and diarrhoea are the
most common symptoms. Redness and sometimes bleeding of the gums
and salivation occur. In the protracted administration of arsenic patients
may complain of numbness and tingling of the fingers. In the large
number of patients to whom I have administered arsenic, often in doses
which might be termed excessive, I have seen only one case in which
numbness and tingling were marked. Pigmentation of the skin I have
seen on several occasions.
In the slow poisoning by the absorption of arsenic in minute doses, as
from wall-paper and fabrics, the symptoms are varied. H. J. Putnam groups
them into the cases in which the symptoms mainly concern the general
nutrition without signs of local irritation ; those in which the symptoms
1012 THE INTOXICATIONS, SUN-STROKE, OBESITY.
are due to irritation of the conjunctivae, mouth, or pharynx ; those with
symptoms pointing to the digestive tract ; cases with marked nervous
phenomena ; and those in which the nutrition of some special part of the
body is involved. The most common symptoms are those of anaemia
and debility, perhaps with slight irritation of the mucous membrane, and
numbness and tingling. How far these symptoms are to be attributed to
the small quantities of arsenic absorbed from wall-papers and fabrics is by
some considered doubtful. That children and adults may take with im-
punity large doses for months without unpleasant effects, and the fact of
the gradual establishment of a toleration which enables Styrian peasants
to take as much as eight grains of arsenious acid in a day, speak strongly
against it.
Arsenical paralysis has the same characteristics as lead-palsy, but the
legs are more affected than the arms, particularly the extensors and pero-
neal group, so that the patient has the characteristic steppage gait of
peripheral neuritis.
The electrical reaction in the muscles may be disturbed before any
loss of power, and when the patient is asked to extend the wrist fully and
to sj^read the fingers slight weakness may be detected early.
V. PTOMAINE POISONING.
In the bacterial decomposition of animal matters chemical compounds
are formed, the putrefactive alkaloids, known as ptomaines and toxines,
some of which are highly poisonous. They differ extraordinarily in their
chemical characters and physiological effects. Some only are poisonous,
and these Brieger has designated as toxines. The specific action of the
micro-organisms in disease is now attributed in large joart to the forma-
tion of these bodies, and the whole question of immunity and protection
is now being worked out in this direction, a special stimulus having been
given of late in the discovery by Hankin of the so-called defensive alka-
loids (see under pneumonia).
Our interest here is in the effects of these poisons when taken with
foods.*
It is quite possible that the leucomaines, the basic substances formed
in the living body, may under certain circumstances be capable of causing
disease. Products also of the bacterial decomposition in the intestines
may be absorbed and act as poisons. Our knowledge on these points is as
yet scanty and uncertain. A suggestive chapter (XIII) upon the subject
is to be found in the work of Vaughan and Xovy.
* For ii full discussion of the whole subject the student is referred to the Manual
upon Ptomaines and Leucomaines, by Vaughan and Novy, second edition, Philadelphia,
1891.
PTOMAINE POLSONING. 1013
Among the more common forms are the following :
(1) Meat Poisoning. — Oases have usually followed the eating of sau-
sages or pork-pie or head-cheese, and also occasionally beef, veal, and mut-
ton. Sausage poisoning, which is known by the name of hotulis7n or
allantiasis^ has long been recognized, and there have been numerous out-
breaks, particularly in parts of Germany. Himilar attacks have been pro-
duced by ham and by head-cheese. The precise nature of the poison in
these cases has not yet been determined. Other outbreaks have followed
the eating of beef and veal. In the majority of these cases the meat has
undergone decomposition, though the change may not have been evident
to the taste. The symptoms of meat poisoning are those of acute gastro-
intestinal irritation. Ballard's description of the Wellbeck cases, quoted
by Vaughan, holds good for a majority of them :
" A period of incubation preceded the illness. In 51 cases where this
could be accurately determined, it was twelve hours or less in 5 cases ; be-
tween twelve and thirty-six hours in 34 cases ; between thirty-six and
forty-eight hours in 8 cases ; and later than this in only 4 cases. In many
cases the first definite symj)toms occurred suddenly, and evidently unex-
pectedly, but in some cases there were observed during the incubation
more or less feeling of languor and ill-health, loss of appetite, nausea, or
fugitive, griping pains in the belly. In about a third of the cases the first
definite symptom was a sense of chilliness, usually with rigors, or trem-
bling, in one case accompanied by dyspnoea ; in a few cases it was giddi-
ness with faintness, sometimes accompanied by a cold sweat and tottering ;
in others the first symptom was headache or pain somewhere in the trunk
of the body — e. g., in the chest, back, between the shoulders, or in the ab-
domen, to which part the pain, wherever it might have commenced, subse-
quently extended. In one case the first symptom noticed was a difficulty
in swallowing. In two cases it was intense thirst. But however the attack
may have commenced, it was usually not long before pain in the abdomen,
diarrhoea, and vomiting came on, diarrhoea being of more certain occur-
rence than vomiting. The pain in several cases commenced in the chest
or between the shoulders, and extended first to the upper and then to the
lower part of the abdomen. It was usually very severe indeed, quickly
producing prostration or faintness, with cold sweats. It was variously de-
scribed as crampy, burning, tearing, etc. The diarrhceal discharges were
in some cases quite unrestrainable, and (where a description of them could
be obtained) were said to have been exceedingly offensive and usually of a
dark color. Muscular weakness was an early and very remarkable symp-
tom in nearly all the cases, and in many it was so great that the patient
could only stand by holding on to something. Headache, sometimes
severe, was a common and early symptom ; and in most cases there was
thirst, often intense and most distressing. The tongue, when observed,
was described usually as thickly coated with a brown, velvety fur, but red
at the tip and edges. In the early stage the skin was often cold to the
1014 THE INTOXICATIONS, SUN-STROKE, OBESITY.
touch, but afterward fever set in, the temperature rising in some cases to
101°, 103°, and 104° F. In a few severe cases, where the skin was actually
cold, tlie patient complained of heat, insisted on throwing off the bed-
clothes, and was very restless. The pulse in the height of the illness be-
came quick, counting in some cases 100 to 128. The above were the
symptoms most frequently noted. Other symptoms occurred, however,
some in a few cases, and some only in solitary cases. These I now pro-
ceed to enumerate. Excessive sweating, cramps in the legs, or in both
legs and arms, convulsive flexion of the hands or fingers, muscular twitch-
ings of the face, shoulders, or hands, aching pain in the shoulders. Joints,
or extremities, a sense of stiffness of the joints, prickling or tingling or
numbness of the hands lasting far into convalescence in some cases, a
sense of general compression of the skin, drowsiness, hallucinations, im-
perfection of vision, and intolerance of light. In three cases (one that of
a medical man) there was observed yellowness of the skin, either general
or confined to the face and eyes. In one case, at a late stage of the ill-
ness, there was some pulmonary congestion and an attack of what was re-
garded as gout. In the fatal cases death was preceded by collapse like
that of cholera, coldness of the surface, pinched features, and blueness of
the fingers and toes and around the sunken eyes. The debility of conva-
lescence was in nearly all cases protracted to several weeks.
" The mildest cases were characterized usually by little remarkable
beyond the following symptoms, viz., abdominal pains, vomiting, diar-
rhoea, thirst, headache, and muscular weakness, any one or two of which
might be absent."
Many instances are on record of poisoning by canned goods, particu-
larly meat. Some of these, according to John G. Johnson, have been cases
of corrosive poisoning from muriate of zinc and muriate of tin used as an
amalgum, but poisonous effects identical with those just described have
followed the use of canned meats.
Certain game birds, particularly the grouse, are stated to be poisonous,
in special districts and at certain seasons of the year.
(2) Poisoning by Milk Products. — Poisoning by cheese has long been
known. In Michigan, in 1883 and 1884, there were nearly 300 cases of
cheese poisoning, and from pieces of the cheese Vaughan separated a sub-
stance which he called tyrotoxicon. Since that date other outbreaks have
been reported. Apparently to this poison also are due the outbreaks fol-
lowing the use of milk, several of which are reported in the manual by
Vaughan and Novy. Still more numerous of late years have been the
cases due to poisonous ice-cream, in which also the tyrotoxicon has been
found.
The symptoms are those of acute gastro-intestinal irritation, and are
similar to those already detailed by Ballard.
(3) Poisoning by Shell-fish and Fish. — Perhaps the most serious form
of iclitlnjsmns^ as the disease is called, is that produced by the mussel,
GRAIN POISONING. 1015
many epidemics of wliicli have been studied of late, more particularly an
outbreak at Wilhelmshaven. Brieger has separated a poison which he has
called mytilotoxin. It has been shown that this exists chiefly in the liver
of the mussel. It does not yet appear to be settled whether there is a spe-
cial poisonous variety or whether the mussel only becomes toxic under
certain conditions. The latter seems to be the most probable view, as
Schmidtmann found that the non-poisonous mussels soon became toxic
when placed in the Wilhelmshaven bay, while those from the bay soon
lost their toxic properties when placed in the open sea.
The symptoms of mussel poisoning follow the eating of either raw or
cooked mussels. The symptoms are those of an acute poisoning with pro-
found action on the nervous system, and without gastro-intestinal symp-
toms. There are numbness and coldness, no fever, dilated pupils, rapid
pulse, and death occurs sometimes within two hours with collapse symp-
toms.
Poisoning occasionally follows the eating of oysters which are stale or
decomposed. The symptoms are usually gastro-intestinal. Certain fish
also cause poisoning, more particularly the salted sturgeon used in parts
of Eussia, which has sometimes proved fatal to large numbers of persons.
In the middle parts of Europe the barb is stated to be sometimes poison-
ous, producing the so-called " barlen cholera^ In China and Japan vari-
ous species of the tetrodon are also toxic, sometimes proving fatal within
an hour, with symptoms of intense disturbance of the nervous system.
Several other poisonous forms are known, which produce symptoms de-
scribed as ichthysmus paralyticus.
VI. GRAIN POISONING.
(1) Ergotism.— The prolonged use of meal made from grains contam^
inated with the ergot fungus {daviceps purpurea) causes a series of symp-
toms known as ergotism, epidemics of which have prevailed in different
parts of Europe. Two forms of this chronic ergotism are described — the
gangrenous and the convulsive or spasmodic. In the former, mortification
affects the extremities— usually the toes and fingers, less commonly the ears
and nose. Preceding the onset of the gangrene there are usually anaes-
thesia, tingling, pains, spasmodic movements of the muscles, and gradual
blood stasis in certain vascular territories.
The nervous manifestations are very remarkable. After a prodromal
stage of ten to fourteen days, in which the patient complains of weakness,
headache, and tingling sensations in different parts of the body, perhaps
accompanied with slight fever, spasmodic symptoms develop, producing
cramps in the muscles and contractures. The arms are flexed and the
legs and toes extended. These spasms may last from a few hours to many
days and relapses are frequent. In severer cases epilepsy develops and the
1016 THE INTOXICATIONS, SUN-STROKE, OBESITY.
patient may die in convulsions. ^lental symptoms are common, mani-
fested sometimes in a preliminary delirium, but more commonly, in the
chronic poisoning, as melancholia or dementia. Posterior spinal sclerosis
occurs in chronic ergotism. In the interesting group of 29 cases studied by
Tuczek and Siemens, nine died at various periods after the infection, and
four post-mortems showed degeneration of the posterior columns. A con-
dition similar to tabes dorsalis is gradually produced by this slow degen-
eration in the spinal cord.
(2) Lathyrism {Lupinosis). — An affection produced by the use of meal
from varieties of vetches, chiefly the Latliyrus sativus and L. cicera.
The grain is popularly known as the chick-pea. The grains are usually
powdered and mixed with the meal from other cereals in the preparation
of bread. As early as the seventeenth century it was noticed that the use
of flour with which the seeds of the Latliyrus were mixed caused stiffness
of the legs. The subject did not, however, attract much attention until
the studies of James Irving, in India, who between 1859 and 1868 pub-
lished several important communications, describing a form of spastic
paraplegia affecting large numbers of the inhabitants in certain regions of
India and due to the use of meal made from the Latliyrus seeds. It also
produces a spastic paraplegia in animals. The Italian observers describe
a similar form of paraplegia, and it has been observed in Algiers by the
French physicians. The condition is that of a spastic paralysis, involving
chiefly the legs, which may proceed to complete paraplegia. The arms
are rarely, if ever, affected. It is evidently a slow sclerosis induced under
the influence of this toxic agent. The precise anatomical condition, so
far as I can ascertain, has not yet been determined.
(3) Pellagra. — This is a nutritional disturbance due to the use of altered
maize. The disease occurs extensively in parts of Italy, in the south of
France, and in Spain. It has not been observed in this country. It pre-
vails extensively among the poorer classes, particularly in the country dis-
tricts, and appears to be associated in some Avay with the use of maize
which (according to most authorities) is fermented or diseased. In the
early stage the symptoms are indefinite, characterized by debility, pains in
the spine, insomnia, digestive disturbances, more rarely diarrhoea. The
first clear manifestation of the disease is the pellagral erythema, which al-
most invariably appears in the spring. This is followed by desiccation
and exfoliation of the epidermis, which becomes very rough and dry, and
occasionally crusts form, beneath which there is suppuration. AVith these
cutaneous manifestations there are digestive troubles — salivation, dyspepsia,
and diarrhoea — which may be of a dysenteric nature. After lasting for a
few months improvement occurs in the milder cases and convalescence is
gradually established. In the more severe and chronic forms there are
pronounced nervous symptoms — headache, backache, spasms, and finally
paralysis and mental disturbance. The paralytic condition affects the
legs and leads gradually to paraplegia. The mental manifestations, which
SUNSTROKE. 1017
are rarely met with until the third or fourth attack, are melancholia or
suicidal mania. Finally, there may bo a condition of the most pronounced
cachexia.
The anatomical changes are indefinite. Chronic degenerative changes
have been found, particularly fatty degeneration and a peculiar pigmenta-
tion in the viscera. The measures to be employed are change in diet, re-
moval from the infected district, and, as a prophylaxis, proper preserva-
tion of the maize.*
VII. SUNSTROKE
{Heat Exhaustion ; Insolation ; Thermic Fever ; Heat-stroke ; Coup de Soleil).
Definition. — A condition produced by exposure to excessive heat.
It is one of the oldest of recognized diseases ; two instances are men-
tioned in the Bible. It w^as long confounded with apoplexy. The Anglo-
Indian surgeons gave admirable descriptions of it. In this country the
most important contributions have come from the New York Hospital and
the Pennsylvania Hospital ; from the former, the studies of Swift and
Darrach, from the latter, the papers of Gerhard, George B. Wood, the
elder Pepper, and Levick. In New Orleans, Bennett Dowler studied the
disease and recognized the difference between heat exhaustion and sun-
stroke. Very little has been added to our knowledge of the disease since
the publication of a monograph by H. C. Wood. Two forms are recog-
nized, heat exhaustion and heat-stroke.
Heat Exhaustion. — Prolonged exposure to high temperatures, particu-
larly when combined with physical exertion, is liable to be followed by
extreme prostration, collapse, restlessness, and in severe cases by delirium.
The surface is usually cool, the pulse small and rapid, and the temperature
•may be subnormal — as low as 95° or 96°. The individual need not neces-
sarily be exposed to the direct rays of the sun, but the condition may
come on when working in close, confined rooms during midsummer. It
may also follow exposure to great artificial heat ; thus the stokers in the
Atlantic steamships sometimes succumb to the effect of the great heat in
the engine rooms.
Sunstroke or Thermic Fever. — The cases are chiefly found in persons
who, while working very hard, are exposed to the sun. Soldiers on the
march with their heavy accoutrements are particularly liable to attack.
In the larger cities of this country the cases are almost exclusively con-
fined to workmen who are much exposed and, at the same time, have
been drinking beer and whisky.
Morbid Anatomy and Pathology.— 7?^^or mortis occurs early.
Putrefactive changes develop with great rapidity. The venous engorge-
* The most elaborate discussion of the subject is by Jules Arnould in the Diction-
naire Encyclopcdique des Sciences Medicales, tome xxii, 188G.
1018 THE INTOXICATIONS, SUN-STROKE, OBESITY.
ment is extreme, particularly in the cerebrum. The left ventricle is con-
tracted (Wood), and the right chamber dilated. The blood is usually
fluid ; the lungs are intensely congested. Parenchymatous changes occur
in the liver and kidneys.
According to Wood, " heat exhaustion with lowered temperature
represents a sudden vaso-motor palsy, i. e., a condition in which the exist-
ing effect of the heat paralyzes the centre in the medulla." On the other
hand, thermic fever is held to be due to paralysis under the influence of
the extreme external heat of the centre in the medulla which regulates
the disposition of the bodily heat. Owing to this disturbance, more heat
is produced and less given off than normally.
Symptoms. — The patient may be struck down and die within an
hour with symptoms of heart failure, dyspnoea, and coma. This form,
sometimes known as the asphyxial, occurs chiefly in soldiers and is graphi-
cally described by Parkes. Death indeed may be almost instantaneous, the
victims falling as if struck upon the head. The usual form in this lati-
tude comes on during exposure, with pain in the head, dizziness, a feel-
ing of oppression, and sometimes nausea and vomiting. Visual disturb-
ances are common, and a patient may have colored vision. Diarrhoea
or frequent micturition may supervene. Insensibility follows, which may
be transient or which deepens into a profound coma. The patients are
usually admitted to hospital in an unconscious state, with the face flushed,
the skin pungent, the pulse rapid and full, and the temperature ranging
from 107° to 110°, or even higher. F. A. Packard states that of the 31 cases
admitted to the Pennsylvania Hospital in the summer of 1887, in a ma-
jority of them the temperature was between 110° and 111°. In one case
the temperature was 112°. The breathing is labored and deep, sometimes
stertorous. Usually there is complete relaxation of the muscles, but
twitchings, jactitation, or very rarely convulsions may occur. The pupils
may at first be dilated, but by the time the cases are admitted to hospital
they are (in a majority) extremely contracted. Petechias may be present
upon the skin. In the fatal cases the coma deepens, the cardiac pulsa-
tions become more rapid and feeble, the breathing becomes hurried and
shallow and of the Cheyne-Stokes type. The fatal termination may
occur within twenty-four or thirty-six hours. Favorable indications are
the recovery of consciousness and a fall in the fever. The recovery in
these cases may be complete. In other instances there are remarkable
after-effects, the most constant of which is a permanent inability to bear
high temperatures. Such patients become very uneasy when the ther-
mometer reaches 80° F. in the shade. An extraordinary instance came
under my notice in which the patient was subsequently so sensitive
to temperatures in the neighborhood of 75° F. that at such times he lived
comfortably only in the cellar, and finally sought refuge in Alaska. Loss
of the power of mental concentration and failure of memory are more
constant and very troublesome sequela?. Such patients are always worse
OBESITY. 1019
in the hot weather. Occasionally convulsions and marked mental disturb-
ance may develop. 11. 0. Wood states that in a case of this kind chronic
meningitis was found.
Guitcras has called attention to a form of fever occurring in the South,
known in Florida as " Florida fever," in the Carolinas as " country fever,"
and in tropical countries asjievre iiifiammatoire The cases last for a vari-
able time, and are mistaken for malaria or typhoid ; but he believes them
to be entirely distinct and due to a prolonged action of the high tempera-
tures. He has called the condition a " continued thermic fever."
The diagnosis of heat exhaustion from thermic fever is readily made,
as the difference between the two conditions is striking. " In solar ex-
haustion the skin is moist, pale, and cool ; the breathing is easy though
hurried ; the pulse is small and soft ; the vital forces fall into a temporary
collapse ; the senses remain entire " (Dowler) ; whereas in sunstroke or
heat apoplexy there is usually unconsciousness and pj^exia.
The mode of onset, together with the circumstances under which it
occurs and the high temperature, permits thermic fever to be readily dif-
ferentiated from apoplexy, and coma from other conditions.
Treatment. — In heat exhaustion stimulants should be given freely,
and if the temperature is below normal the hot bath should be used
Ammonia may be given if necessary. In thermic fever the indications
are to reduce the temperature as rapidly as possible. This may be done
by placing the patient in a bath at 70°. Eubbing the body with ice was
practised at the I^ew York Hospital by Darrach in 1857, and is an excel-
lent procedure to lower the temperature rapidly. Ice-water enemata may
also be employed. At the Pennsylvania Hospital in the summer of 1887
the ice-pack was used with great advantage. Of 31 cases only 12 died,
a result probably as satisfactory as can be obtained, considering that many
of the patients are almost moribund when brought to hospital. It should
be compared with Swift's statistics, in which of 150 cases 78 died. In the
cases in which the symptoms are those of intense asphyxia, and in which
death may take place in a few minutes, free bleeding should be practised,
a procedure which saved Weir Mitchell when a young man. Of other rem-
edies, the antipyretics have been employed, and may be given when there
is any special objection to hydrotherapy, for which, however, they cannot
be substituted.
VIII. OBESITY.
Corpulence, an excessive development of the bodily fat, is a condition
for which the physician is frequently consulted, and for which much may
be done by a judicious arrangement of the diet. The tendency to polysarcia
or obesity is often hereditary, and is particularly apt to be manifest after
the middle period of life. It may, however, be seen early, and in this
country it is not very uncommon in young girls and young boys.
1020 THE INTOXICATIONS, SUN-STROKE, OBESITY.
A very important factor is overeating, a vice which is more preva-
lent and only a little behind overdrinking in its disastrous effects. A
majority of persons over forty years of age habitually eat too much. In
some of the most aggravated cases of obesity, however, this plays no part,
and the unfortunate victim may be a notoriously small eater. A second
element is lack of proper exercise ; a third less important factor is the tak-
ing largely of alcoholic beverages, particularly beer.
In obesity it is now generally conceded that the carbohydrates, which
were so long blamed, are not at fault, since they are themselves converted
into water and carbon dioxide. On account, however, of the facility with
which they are utilized for the purposes of oxidation the albuminous ele-
ments of the food are less readily oxidized, not so fully decomposed, and
the fat is in reality separated from them. So, too, the fats themselves are
not so prone to cause obesity as the carbohydrates, being less readily ox-
idized and interfering less with the complete metabolism of the albumi-
nous elements.
Many plans are now advised for the reduction of fat, the most impor-
tant of which are those of Banting, Ebstein, and Oertel. In the Banting
method the amount of food is reduced, the liquids are restricted, and the
fats and carbohydrates excluded.
Ebstein recommends the use of fat and the rapid exclusion of the carbo-
hydrates. The following is an example of his dietary :
Breakfast (G A. m. in summer, 7.30 a. m. in winter). — White bread,
well toasted (rather less than two ounces) and well covered with butter.
Tea, without milk or sugar, eight or nine ounces.
Dinner^ 2 p. m. — Soup made with beef-marrow. Fat meat, with fat
sauce, four to five ounces. A moderate quantity of asparagus, spinach,
cabbage, peas, and beans. Two or three glasses of light Avhite wine.
After the meal, a large cup of tea without milk or sugar.
Supper^ at 7.30 p. m. — An Qgg^ a little roast meat, with fat. About
an ounce of bread, well covered with butter. A large cup of tea, without
milk or sugar.
Oertel's method has already been considered in connection with the
treatment of fatty heart, and is combined with systematic bodily exercise.
It is particularly adapted for stout persons with weak heart.
The so-called Schweninger cure is in reality Oertel's, with the sole
modification of the forbidding of any fluid at meals. Liquids must be
taken more than two hours after the food.
Yeo, after a full consideration of the various methods, gives the follow-
ing useful summary :
" The albuminates in the form of animal food should be strictly lim-
ited. Farinaceous and all starchy foods should be reduced to a minimum.
Sugar should be entirely prohibited. A moderate amount of fats, for the
reasons given by Ebstein, should be allowed.
" Only a small quantity of fluid should be permitted at meals, but
OBESITY. 1021
enough should bo allowed to aid in the solution and digestion of the food.
Hot water or warm aromatic beverages may be taken freely between meals
or at the end of the digestive process, especially in gouty cases, on account
of their eliminative action.
"No beer, porter, or sweet wines of any kind to be taken; no spirit,
except in very small quantity. It should be generally recognized that tlie
use of alcohol is one of the most common provocatives of obesity. A
little Ilock, still Moselle, or light claret, with some alkaline table water is
all that should be allowed. The beneficial effects of such diet will be aided
by abundant exercise on foot and by the free use of saline purgatives, so
that we may insure a complete daily unloading of the intestinal canal.
" It is only necessary to mention a few other details. Of animal foods,
all kinds of lean meat may be taken, poultry, game, fish (eels, salmon,
and mackerel are best avoided), eggs.
" Meat should not be taken more than once a day, and not more than
six ounces of cooked meat at a time. Two lightly boiled or poached eggs
may be taken at one other meal, or a little grilled fish.
" Bread should be toasted in thin slices and completely, not browned on
the surface merely.
" Hard captain's biscuits may also be taken.
" Soups should be avoided, except a few tablespoonfuls of clear soup.
" Milk should be avoided, unless skimmed and taken as the chief article
of diet. All milk and farinaceous puddings and pastry of all kinds are
forbidden. Fresh vegetables and fruit are permitted.
'' It is important to bear in mind that the actual quantity of food per-
mitted must have a due relation to the physical development of the indi-
vidual, and that what would be adequate in one case might be altogether
inadequate in the case of another person of larger physique." *
* A System of Therapeutics, vol. i, edited by H. A. Hare, Philadelphia, 1891.
SECTION XL
DISEASES DUE TO ANIMAL PAEASITES.
I. PSOROSPERMIASIS.
Under this term are embraced several affections produced by the spo-
rozoa. These parasites belonging to the lowest division of the protozoa,
are also known as psorosperms and gregarinidse. They are extraordinarily
abundant in the invertebrates, and are not uncommon in the higher mam-
mals. The entire group of blood parasites, hsematozoa, which live within
tlie corpuscles, are closely related to them. Psorosperms are, as a rule,
parasites of the cells — cytozoa. The commonest and most suitable variety
for study is the coccidium oviforme of the rabbit, which produces a dis-
ease of the liver in which the organ is studded throughout with whitish
nodules, ranging in size from a pin's head to a split pea. On section each
nodule is seen to be a dilated portion of a bile duct ; the walls are lined
with epithelium in the interior of which are multitudes of ovoid bodies —
the coccidia. Another very common form occurs in the muscles of the
pig, the so-called Rainey's tube, which is an ovoid body within the sar-
colemma containing a number of small, sickle-shaped, unicellular organ-
isms.
These bodies probably play a more important role in human pathology
than has hitherto been thought. The cases reported may be grouped un-
der tlie following divisions : internal and external.
(1) Internal Psorospermiasis. — In a majority of the cases of this group
the psorosperms have been found in the liver, producing a disease similar
to that which occurs in rabbits. In Guebler's case there were tumors
which could be felt in the liver during life, and they were determined by
Leuckart to be due to coccidia. In W. B. Iladdon's case the patient was
admitted to St. Thomas's Hospital with slight fever, drowsiness, and grad-
ual unconsciousness ; death occurred on the fourteenth day of observa-
tion. Whitish neoplasms were found upon the peritonaeum, omentum, and
on the layers of the pericardium ; and a few were found in tlie liver, spleen,
and kidneys. A somewhat similar case, though more remarkable, as it ran
a very acute course, is reported by Silcott. A woman, aged fifty-three,
admitted to St. Mary's Hospital, was thought to be suffering from typhoid
PSOROSPERMIASIS. 1023
fever. She had had a chill six weeks before admission. There was fever
of an intermittent type, slight diarrhcjoa, nausea, tenderness over the liver
and spleen, and a dry tongue ; death occurred from heart-failure, "^riie
liver was enlarged, weighed eighty-three ounces, and in its substance there
were caseous foci, around each of which was a ring of congestion. The
spleen weighed sixteen ounces and contained similar bodies. The ileum
presented six papule-like elevations. The masses resembled tubercles,
but on examination coccidia were found.
The parasites are also found in the kidneys and ureters. Cases of this
kind have been recorded by Bland Sutton and Paul Eve. In the case
reported by Eve the symptoms were hsematuria and frequent micturition,
and death took place on the seventeenth day. The nodules throughout
the pelvis and ureters have been regarded as mucous cysts. In a case
reported by Joseph Griffiths the tumors in the ureter caused hydrone-
phrosis.
(2) Cutaneous Psorospermiasis. — (a) Follicular. — This remarkable
skin-disease was originally described by J. C. White, under the name of
keratosis follicular is. Darier, of Paris, has shown that this is really a
parasitic affection. The lesions are chiefly on the face, the flanks, and the
inguinal regions. It is at first papular, surmounted by a grayish crust, dry
and hard. The lesions finally become confluent, and form a series of
irregular elevations giving a rasp-like feeling to the touch.
Microscopical examination shows that in these papillomatous growths
there are numerous organisms corresponding to psorosperms. At the St.
Louis Hospital, in Paris, Darier was kind enough to show me the cases and
the specimens from them. Xo one accustomed to the appearance of
psorosperms as seen in the lower animals could question the truly para-
sitic nature of these bodies. A case of the disease has been reported in
this country by A. R. Robinson.
{h) Paget' s Disease of the Nipple. — In this affection, formerly regarded
as an eczema, psorosperms are constantly present, as shown by Darier,
A. B. Macallum, and others. They are readily demonstrated, without any
special preparation, and here, too, of the nature of the bodies there can be
no question.
In moUuscum contagiosum and in epithelioma many observers have
noted the presence of bodies which lie in and between the epithelial cells
and have some resemblance to psorosperms. The bodies are readily seen
in sections of epithelioma, but they lack the sharply defined characters of
the coccidia which are present in Paget's disease and in White's keratosis.
1024 DISEASES DUE TO ANIMAL PARASITES.
II. DISTOMIASIS.
Several forms of trematodes or flukes are parasitic in man, and when
in numbers may cause serious disease.
(1) Liver Flukes. — The following varieties of flukes have been found :
The dlstoma hepaticum., a very common parasite in ruminants, which has a
length of from twenty-eight to thirty-two millimetres. The distoma
lanceolatum^ a much smaller form, from eight to ten millimetres in length,
which is also very common in sheep and cattle. The distoma crassum,
the largest form, measuring from four to eight centimetres in length.
One or two other less important forms have occasionally been met with.
The studies of the Japanese physicians have brought to light the interest-
ing fact that there is a distoma widely endemic in certain provinces in
that country. Two forms have been described, the distoma endemicum,
and the distoma jjerfiiciosurn, about which there is still a doubt whether
they are different species or not. The studies of Ijima indicate that they
are probably the same. According to Baelz, fully twenty per cent of the
inhabitants of certain provinces are affected.
The flukes occupy the bile-passages and the upper portion of the
small intestine. "When in large numbers they may cause serious and
fatal disease of the liver, usually with ascites and jaundice. The liver
may be enormously enlarged ; in Kichner's case it weighed eleven pounds.
The flukes may cause a chronic cholangitis, leading to great thickening
or even calcification of the walls of the bile-duct.
The endemic fluke disease of Japan is characterized by enlargement of
the liver, emaciation, diarrhoea, and frequently ascites.
(2) The Blood Fluke; Bilharzia Hcematohia. — This trematode is
found in Egypt, southern Africa, and Arabia, and is the cause in these
countries of the endemic haematuria. The female is about two centi-
metres in length, cylindrical, filiform, and about '07 millimetre in di-
ameter. The parasite lives in the venous system, particularly in the por-
tal vein, and in the veins of the spleen, bladder, kidneys, and mesentery.
According to Bilharz, at least fifty per cent of the lower classes in Egypt
are infected with it. It is not yet known how the parasite gains entrance
to the body. In all probability it is by drinking impure water contain-
ing the embryos.
The symptoms are due to changes in the mucous membrane of the
urinary organs caused by the presence of the parasites in the blood-ves-
sels of these parts. Haematuria is the first and most constant symptom,
leading gradually to anaemia. There is generally pain during micturi-
tion. The blood is not constant in the urine. The ova of the Bilharzia
are readily seen under a microscope with a low power. Tliey are ovoid in
shape, translucent, with a small spike at one end. The embryo can be
readily seen.
The disease is rarely fatal ; a great majority of the cases recover. Chil-
DISEASES CAUSED BY NEMATODES. 1025
dren are more commonly attacked than grown persons, and the disease
often disappears by the time of puberty.
(3) Bronchial Fluke; Distoma Ringeri ; Parasitic Ilcemoptysis. —
In parts of China, Japan, and Formosa there is an epidemic disease, de-
scribed by Ringer and Manson, characterized by attacks of cough and
haemoptysis associated with the presence of a small fluke in the bronchial
tubes.
III. DISEASES CAUSED BY NEMATODES.
I. ASCARIASIS.
{a) Ascaris lumhricoides^ the most common human parasite, is found
chiefly in children. The female is from seven to twelve inches in length,
the male from four to eight inches. The worm is cylindrical, pointed at
both ends, and has a yellowish-brown, sometimes a slightly reddish color.
Four longitudinal bands can be seen, and it is striated transversely. The
ova, which are sometimes found in large numbers in the faeces, are small,
brownish-red in color, elliptical, and have a very thick covering. They
measure -075 millimetre in length and -058 millimetre in width. They
develop outside the body, but the life history is not known. The para-
site occupies the upper portion of the small intestine. Usually not more
than one or two are present, but occasionally they occur in enormous
numbers. The migrations are peculiar. They may pass into the stom-
ach, from which they may be ejected by vomiting, or they may crawl up
the oesophagus and enter the pharynx, from which they may be with-
drawn. A child, under my care in the small-pox department of the Gen-
eral Hospital, during convalescence, withdrew in this way more than
thirty round worms within a few weeks. In other instances the worm
passes into the lar\Tix, and has been known to cause fatal asphyxia, or
passing into the trachea, to cause gangrene of the lung. They may
pass into the Eustachian tube and appear at the external meatus. The
most serious migration is into the bile-duct. There is a specimen in the
Wistar-Horner Museum of the University of Pennsylvania in which not
only the common duct, but also the main branches throughout the liver
are enormously distended and packed with numerous round worms. The
bowel may be perforated by them and peritonitis result.
The symptoms are not definite. When a few are present they may be
passed without causing disturbance. In children there are irritative
symptoms usually attributed to worms, such as restlessness, irritability,
picking at the nose, grinding of the teeth, twitchings, or convulsions.
These symptoms may be marked in very nervous children.
Treatment. — Santonin can be given, mixed with sugar, in doses of
from one to three grains for a child and three to five grains for an adult,
followed by a calomel or a saline purge. The dose may be given for
1026 DISEASES DUE TO ANIMAL PARASITES.
three or four days. An unpleasant consequence which sometimes follows
the administration of this drug is xanthopsia or yellow vision.
(b) Oxyuris Vermicularis (Thread-woi'm ; Pin-worm). — This com-
mon parasite occupies the rectum and colon. The male measures about
four millimetres in length, the female about ten millimetres. They pro-
duce great irritation and itching, particularly at night, symptoms which
become intensely aggravated by the nocturnal migration of the parasites.
The patients become extremely restless and irritable, the sleep is often
disturbed, and there may be loss of appetite and anaemia. Though most
common in children the parasite occurs at all ages.
The worm is readily detected in the faeces. Infection probably takes
place through the water or possibly through salads, such as lettuces and
cresses. A person the subject of the worms passes ova in large numbers
in the faeces, and the possibility of reinfection must be scrupulously
guarded against.
The treatment is simple, though occasionally there are instances in
which all forms of medication are resisted. A case is mentioned of a gen-
tleman, aged forty, who had suffered from childhood and had failed
to obtain any benefit from prolonged treatment by many helminthologists.
Santonin may be used in small doses, and mild purgatives, particularly
rhubarb. Large injections containing carbolic acid, vinegar, quassia, aloes,
or turpentine may be employed. In children the use of cold injections of
strong salt and water is usually efficacious. They should be repeated for
at least ten days. In giving the injection care should be taken to have
the hips well elevated so that the fluid can be retained as long as possible.
For the intense itching and irritation at night vaseline may be freely
used or belladonna ointment.
II. Trichiniasis.
The trichina spiralis in its adult condition lives in the small intestine.
The disease is produced by the embryos, which pass from the intestines
and reach the voluntary muscles, where they finally become encapsulated
— muscle trichinae. It is in the migration of the embryos that the group
of symptoms known as trichiniasis is produced.
Descriptmi of the Parasites. — {a) Adult or intestinal form. The fe-
male measures from three to four millimetres; the male, 1*5 millimetre,
and has two little projections from the hinder end.
(b) The embryo or muscle trichina is from 0*6 to one millimetre in
length and lies coiled in an ovoid capsule, which is at first translucent, but
subsequently opaque and infiltrated with lime salts. The worm presents a
pointed head and a somewhat rounded tail.
When flesh containing the trichinae is eaten by man or by any ani-
mal in which the development can take place, the capsules are digested
and the trichinae set free. They pass into the small intestine, and about
DISEASES CAUSED BY NEMATODES. 1027
the third day attain thoir full growth and become sexually mature. Vir-
chow's experiments have shown that on the sixth or seventh day the em-
bryos are fully developed. The young produced by each female trichina
have been estimated at several hundred. Leukart thinks that various
broods are developed in succession, and that as many as a thousand
embryos may be produced by a single worm. The time from the inges-
tion of the flesh containing the muscle trichinae to the development of the
brood of embryos in the intestines is from seven to nine days. As soon
as born the embryo trichinae leave the intestines ; wandering through the
peritonaeum and the connective tissues, probably through the mesentery
and retroperitoneal tissues — some hold by means of the blood current —
they finally reach the muscles, which constitute " the seat of election."
After a preliminary migration in the intermuscular connective tissue they
penetrate the primitive muscle fibres, and in about two weeks develop into
the full-grown muscle form. In this process an interstitial myositis is ex-
cited and gradually an ovoid capsule develops about the parasite. Two,
occasionally three or four, worms may be seen within a single capsule.
This process of encapsulation has been estimated to take about six weeks.
Within the muscles the parasites do not undergo further development.
Gradually the capsule becomes thicker, and ultimately lime salts are
deposited within it. This change may take place in man within four or
five months. In the hog it may be deferred for many years. The cal-
cification renders the cyst visible, and since first seen by Tiedemann, in
1822, and Hilton, in 1832, these small, opaque, oat-shaped bodies have been
familiar objects to demonstrators of normal and morbid anatomy. The
trichinae may live within the muscles for an indefinite period. They have
been found alive and capable of developing as late as twenty or even
twenty-five years after their entrance into the system. In many in-
stances, however, the worms are completely calcified. The trichina occurs
in swine, in the rat, occasionally in mice and cats ; it has been found also
in the fox and a few other animals. The parasite was first found in the
hog by the late Joseph Leidy. Experimentally, guinea-pigs and rabbits
are readily infected by feeding them with muscle containing the larval
form. Dogs are infected with difficulty; cats more readily. Experi-
mentally, animals sometimes die of the disease if large numbers of the
parasites have been eaten. In the hog the trichinae, like the cysticerci,
cause few if any symptoms. An animal the muscles of which are swarm-
ing with living trichinae may be well nourished and healthy-looking. An
important point also is the fact that in the hog the capsule does not readi-
ly become calcified, so that the parasites are not visible as in the human
muscles. For a long time tlie trichina was looked upon as a pathological
curiosity, but in 18G0 Zenker discovered in a girl in the Dresden Hospital
wlio had symptoms of typhoid fever both the intestinal and the muscle
forms of the trichinae, since which time the disease has been thoroughly
etudied.
66
1028 DISEASES DUE TO ANIMAL PARASITES.
Man is infected by eating the flesh of trichinous hogs. The incidence
of the disease in swine varies much in different countries. In Germany,
where a thorough and systematic microscopic examination of all swine
flesh is made, the proportion of trichinous hogs is about 1 in 1,852. At
the Berlin abattoir, where the microscopic examination is conducted by a
staff of over eighty men and women, two portions are taken from the ab-
dominal muscles, from the diaphragm, and from the intercostal muscles,
and one piece from the muscles of the lar)rnx and tongue. A special com-
pressor is used to flatten the fragments of the muscle, and the examination
is made with a magnifying power of from seventy to one hundred diameters.
During the three years ending in 1885 there were 603 trichinous hogs de-
tected, a ratio of 1 to 1,292. Statistics are not available in England. In
the United States systematic inspection is unknown, and the statistics are
by no means extensive enough. " Taking all the examinations of Amer-
ican pork thus far made, both at home and abroad, and we have a total of
298,782, in which trichinae were found 6,280 times, being 2'1 per cent, or
1 to 48 " (Salmon, 1884).
In 1883, in conjunction with A. W. Clement, I examined 1,000 hogs
at the Montreal abattoir, and found only 4 infected. There is no reason
to believe that the hog of this country is less liable to trichina than the
German animal.
Modes of Infection. — The danger of infection depends entirely upon
the mode of preparation of the flesh. Thorough cooking, so that all parts
of the meat reach the boiling point, destroys the parasites ; but in large
Joints the central portions are often not raised to this temperature. The
frequency of the disease in different countries depends largely upon the
habits of the people in the preparation of pork. In North Germany,
where raw ham and ivurst are freely eaten, the greatest number of cases have
occurred. In South Germany, France, and England cases are rare. In
this country the greatest number of persons attacked have been Germans.
Salting and smoking the flesh are not always sufficient, and the Havre ex-
periments showed that animals are readily infected when fed with portions
of the pickled or the smoked meat as prepared in tliis country. Carl
Friinkel, however, states that the experiments on this point have been
negative, and that it is very doubtful if any cases of trichiniasis in Ger-
many have been caused by American pork.
Frequencxj of Infection. — The dissecting-room and post-mortem statis-
tics show that from one half to two per cent of all bodies contain trichiucT.
Of 1,000 consecutive autopsies of which I have notes the trichinas were
present in 6 instances. I have, in addition, seen them in two dissecting-
room cases and in two bodies at the Philadelphia Hospital.
The disease often occurs in epidemics, a large number of persons being
infected from a single source. Among the best known of these outbreaks
are the Iledersleben, in which there were 337 persons affected, and the
Emerslcbcn, in which there were 250 persons attacked. The extensive
DISEASES CAUSED BY NEMATODES. 1020
outbreaks of this sort have been, with few exceptions, in North Germany.
Alfred Mann, after a careful search, at my request, of the literature in the
Surgeon-General's library, finds records of 450 cases in this country. The
two largest groups of cases were at Astoria, Ore., reported by Kinney, 15
cases and one death ; and at St. Paul, Minn., reported by Persons and
Andrews, 15 cases and three deaths.
Symptoms. — The ingestion of trichinous flesh is not necessarily
followed by the disease. When a limited number are eaten only a few em-
bryos pass to the muscles and may cause no symptoms. AV ell-characterized
cases present a gastro-intestinal period and a period of general infection.
In the course of a few days after eating the infected meat there are
signs of gastro-intestinal disturbance — pain in the abdomen, loss of appe-
tite, vomiting, and sometimes diarrhoea. The preliminary symptoms, how-
ever, are by no means constant, and in some of the large epidemics cases
have been observed in which they have been absent. In other cases the
gastro-intestinal features have been marked from the outset, and the attack
has resembled cholera nostras. Pains in different parts of the body, gen-
eral debility, and weakness have been noted in some of the epidemics.
The invasion symptoms develop between the seventh and the tenth day,
sometimes not until the end of the second week. There is fever, except in
very mild cases Chills are not common. The thermometer may register
102° or 104°, and the fever is usually remittent or intermittent. The mi-
gration of the parasites in the muscles excites a more or less intense myo-
sitis, which is characterized by pain on pressure and movement, and by
swelling and tension of the muscles. The limbs are placed in the posi-
tions in which the muscles are in least tension. The involvement of the
muscles of mastication and of the larynx may cause difficulty in chewing
and swallowing. In -severe cases the involvement of the diaphragm and
intercostal muscles may lead to intense dyspnoea, which sometimes proves
fatal. (Edema, a feature of great importance, may be early in the face.
Later it develops in the extremities when the swelling and stiffness of the
muscles are at their height. Profuse sweats, tingling and itching of the
skin, and in some instances urticaria, have been described. The general
nutrition is much disturbed and the patient becomes emaciated and often
anaemic, particularly in the protracted cases. The patellar tendon reflex
may be absent. The patients are usually conscious, except in cases of very
intense infection, in which the delirium, dry tongue, and tremors give a
picture similar to typhoid fever. In addition to the dyspnoea, present in
the severer cases, there may be bronchitis, and in the fatal cases pneu-
monia or pleurisy. In some epidemics polyuria has been a common symp-
tom. Albuminuria is frequent.
The intensity and duration of the symptoms depend entirely upon the
grade of infection. In the mild cases recovery is complete in from ten to
fourteen days. In the severe forms convalescence is not established for
six or eight weeks, and it may be months before the patient recovers the
1030 DISEASES DUE TO ANIMAL PARASITES.
muscular strength. One case in the Hedersleben epidemic was weak eight
years after the attack.
Of 72 fatal cases in the Hedersleben epidemic the greatest mortality
occurred in the fourth and fifth and sixth weeks ; namely, 52 cases. Two
died in the second week with severe choleraic symptoms.
The mortality has ranged in different outbreaks from one or two per
cent to thirty per cent. In the Hedersleben epidemic 101 persons died.
Among the 456 cases reported in this country there were 122 deaths.
The anatomical changes are chiefly in the voluntary muscles. In the
early stages they look normal, but in the fourth or fifth week grayish-
white areas appear in which the muscle fibres are extensively degenerated
and in the neighborhood of the trichinae there is an acute interstitial
myositis. Cohnheim has described a fatty degeneration of the liver and
enlargement of the mesenteric glands. At the time of death in the
fourth or fifth week or later the adult trichinae are still found in the in-
testines.
The prognosis depends much upon the quantity of infected meat which
has been eaten and the number of trichinae which mature in the intestines.
In children the outlook is more favorable. Early diarrhoea and moderately
intense gastro-intestinal symptoms are, as a rule, more favorable than con-
stipation.
Diagnosis. — This is perfectly clear when a large number of persons
are infected at once and the parasites have been found in the ham or sau-
sages. The worms may be discovered in the stools. The stools should be
spread on a glass plate or black background and examined Avith a low-
power lens, when the trichinae are seen as small, glistening, silvery threads.
In doubtful cases the diagnosis may be made by the removal of a small
fragment of muscle. A special harpoon has been devised for this purpose
by means of which a small portion of the biceps or of the pectoral muscle
may be readily removed. Under cocaine anaesthesia an incision may be
made and a small fragment removed. The disease may be mistaken for
acute rheumatism, particularly as the pains are so severe on movement,
but there is no special swelling of the joints. The tenderness is in the
muscles both on pressure and on movement. The intensity of the gastro-
intestinal symptoms in some cases has led to the diagnosis of cholera.
Many of the former epidemics were doubtless described as typhoid fever,
which the severer cases, owing to the prolonged fever, the sweats, the de-
lirium, dry tongue, and gastro-intestinal symptoms, somewhat resemble.
The pains in the muscles, swelling, oedema, and shortness of breath are the
most important diagnostic points. Under acute myositis reference has
ah'cady been made to the cases which closely resemble trichiniasis. The
epidemic in 1879 on board the training ship Cornwall presented symp-
toms similar to those of trichiniasis. One patient died. Two months after
burial the body was examined, and living and dead nematode worms were
found whicli, as Bastian showed, were not the trichina, but a rhabditis.
DISEASES CAUSED BY NEMATODES. 1031
They were probably not parasitic, but entered the body of tlie cadet after
burial.
Prophylaxis. — It is not definitely known how swine become dis-
eased. It has been thought that they are infected from rats about slaugh-
ter-houses, but it is just as reasonable to believe that the rats are infected
by eating portions of the trichinous flesh of swine. The swine should, as
far as possible, be grain-fed, and not, as is so common, allowed to eat offal.
The most satisfactory prophylaxis is the complete cooking of pork and
sausages, and to this custom in England, France, South Germany, and
particularly in this country, immunity is largely due.
Treatment. — If it has been discovered within twenty-four or thirty-
six hours that a large number of persons have eaten infected meat, the
indications are to thoroughly evacuate the gastro-intestinal canal. Purga-
tives of rhubarb and senna may be given, or an occasional dose of calomel.
Glycerin has been recommended in large doses in order that by passing
into the intestines it may by its hygroscopic properties destroy the worm.
Male-fern, kamala, santonin, and thymol have all been recommended in
this stage. There is no doubt that diarrhoea in the first week or ten days
of the infection is distinctly favorable. The indications in the stage of in-
vasion are to relieve the pains, to secure sleep, and to support the patient's
strength. There are no medicines which have any influence upon the
embryos in their migration through the muscles.
III. Al^CHYLOSTOMIASIS.
The dochviius or strongylus duodenalis^ also known as the sclerostomum
or ancliylostomum duodenale is the only strongyle harmful to man. It
belongs to the same family as the strongylus armatus^ which causes the
verminous aneurism in the horse. The parasites live in the upper por-
tion of the small intestine, chiefly in the jejunum. They are easily seen,
the male having a length of from six to ten millimetres, and the female
from ten to eighteen millimetres. The mouth is provided with a series of
tooth-like hooks, by means of which the parasite attaches itself to the
mucous membrane. The male has a prominent expansion or bursa at the
tail end. The existence of the parasite has long been known, but it was
not thought to be pathogenic until Griesinger demonstrated its association
with the Egyptian chlorosis. It has also been shown to be the cause of
the anaemia to which miners and brick-makers are subject. Throughout
Europe the disease has been widely spread by the employment of Italian
and Polish laborers. In certain Italian provinces it is extremely preva-
lent and serious. It occurs in India and in Brazil, and has been described
in Jamaica (Strachan). Dolley states that the parasite was described many
years ago by physicians in the Southern States, but no recent observations
upon the disease have been made in this country.
Symptoms. — The parasites withdraw blood by suction, and the
1032 DISEASES DUE TO ANIMAL PARASITES.
symptoms result from this slow depletion. In the early stage there may
only be gastric or gastro-intestinal disturbance, but if the parasites are
present in large numbers anaemia is gradually produced and constitutes
the characteristic feature of the disease. The Egyptian chlorosis, brick-
maker's anaemia, tunnel anaemia, miner's cachexia, and mountain anaemia
are due to this cause. The clinical course is variable. In some instances
the anaemia develops acutely and reaches a high grade within a short time,
causing great shortness of breath and oedema. There is serious disturb-
ance of nutrition, sometimes diarrhoea and colicky pains ; but the most
pronounced symptom is the pallor and the associated phenomena of
chronic anaemia. The lesions of the intestines are those of chronic
catarrh, and small haemorrhages occur in the mucosa. Dilatation and
hypertrophy of the heart have been found in many cases.
The diagnosis is not difficult. The ova, which are abundant in the
stools, are oval, about -05 millimetre in length, and possess a thin,
transparent shell. There is no operculum, as in the ovum of the oxyuris,
and the yolk is unsegmented. The larvae develop in moist earth and
readily get into the drinking water, through which infection occurs.
The systematic use of latrines and the boiling of all water used for
drinking purposes are the important prophylactic measures. The treat-
ment should be directed to the destruction of the parasites in the intes-
tine, which may be effected by the male fern or by thymol, which Sonsino
recommends highly. It is given in capsules of half a drachm every hour
for four doses. A purgative is not necessary.
IV. FlLARIASIS.
Under this term may be considered the morbid conditions induced by
the filai'ia saiiguinis hominis, or the filaria Bancroft i^ the name employed
to designate the adult worm, which was discovered by Bancroft, of Bris-
bane. In the adult form the worm lives in the lymphatics. The female
is thus described by Patrick Manson, whose studies on this parasite have
been so important : " A long, slender, hair-like animal quite three inches
in length but only one one hundredth inch in breadth, of an opaline ap-
pearance, looking, as it lies in the tissues, like a delicate thread of catgut
animated and wriggling. A narrow alimentary canal runs from the sim-
ple club-like head to within a short distance of the tail, the remainder of
the body being almost entirely occupied by the reproductive organs. The
vagina opens about one twenty-fifth of an inch from the head ; it is very
short, and bifurcates into two uterine horns, which, stuffed with embryos
in all stages of development, run backward nearly to the tail." The male
worm is much smaller and has only occasionally been found. The female
produces an extraordinary number of embryos, which enter the blood
current through the lymphatics. Each embryo is witliin its sliell, which
is elongated, scarcely perceptible, and in no way impedes the movements.
DISEASES CAUSED BY NEMATODES. 1033
They are about the ninetieth part of an inch in length and the diameter
of a red blood-corpuscle in thickness, so that they readily pass through the
capillaries. They move with the greatest activity and form very striking
and readily recognized objects in a blood-drop under the microscope. A
remarkable feature is the periodicity in the occurrence of the embryos in
the blood. In the daytime they are almost or entirely absent, whereas at
night, in typical cases, they are present in large numbers. If, however,
as Stephen Mackenzie has shown, the patient, reversing his habits, sleeps
during the day, the periodicity is reversed. The further development of
the embyros appears to be associated with the mosquito, which at night
sucks the blood and in this way frees them from the body. Some slight
development takes place within the body of the mosquito, and it is prob-
able that the embryos are set free in the water after the death of the host.
The further development is not known, but it is probably in drinking
water. The filarige may be present in the body without causing any symp-
toms. In animals blood filariae are very common and rarely cause incon-
venience. It is only when the adult worms or the ova block the lymph chan-
nels that certain definite symptoms occur. Manson suggests that it is the
ova (prematurely discharged), which are considerably shorter and thicker
than the full-grown embryos, which block the lymph channels and pro-
duce the conditions of haematochyluria, elephantiasis, and lymph-scrotum.
The parasite is widely distributed, particularly in tropical and sub-
tropical countries. Guiteras has shown that the disease prevails exten-
sively in the Southern States, and since his paper appeared contributions
have been made by Matas, of Xew Orleans, Mastin, of Mobile, and De
Saussure, of Charleston.
The effects produced may be described under the above-mentioned
conditions.
(a) Hcematochyluria. — Without any external manifestations, and in
many cases without special disturbance of health, the subject from time to
time passes urine of an opaque white, milky appearance, or bloody, or a
chylous fluid which on settling shows a slightly reddish clot. The urine
may be normal in quantity or increased. The condition is usually inter-
mittent, and the patient may pass normal urine for weeks or months at a
time. Microscopically, the chylous urine contains minute molecular fat
granules, usually red blood-corpuscles in various amounts. It was in
urine of this kind that Wucherer, of Bahia, first detected the filarian em-
bryos. It is remarkable for how long the condition may persist without
serious impairment of the health. A patient, sent to me by Dawson, of
Charleston, has had haematochyluria intermittently for eighteen years.
The only inconvenience has been in the passage of the blood-clots which
collect in the bladder. At times he has also uneasy sensations in the lum-
bar region. The embryos are present in his blood at night in large num.
bers. Chyluria is not always due to the filaria. The non-parasitic form
of the disease has already been considered.
1034 DISEASES DUE TO ANIMAL PARASITES.
Opportunities for studying the anatomical condition of these cases
rarely occur. In the case described by Stephen Mackenzie the renal and
peritoneal lympli plexuses were enormously enlarged, extending from the
diaphragm to the pelvis. The thoracic duct above the diaphragm was
impervious.
(b) Lympli-scroticm and certain forms of elejyltantiasis are sometimes
caused by the filaria. In the former the tissues of the scrotum are enor-
mously thickened and the distended lymph-vessels may be plainly seen.
A clear, sometimes a turbid, fluid follows puncture of the skin. The
parasites are not always to be found. I have examined two typical cases
without finding filaria in the exuded fluids or in the blood at night. So
also the majority of cases of elephantiasis which occur in this country are
non-parasitic. In China it is stated that the parasites occur in all these
cases.*
V. Dracontiasis (Guinea-ivorm Disease).
The Filaria or Dracunculus medinensis is a widely spread parasite in
parts of Africa and the East Indies. In the United States cases occasion-
ally occur. Jarvis reports a case in a post chaplain who had lived at Fort-
ress Monroe, Va., for thirty years. Van Harlingen's patient, a man aged
forty-seven, had never lived out of Philadelphia, so that the worm must
be included among the parasites of this country. A majority of the cases
reported in American journals have been imported.
Only the female is known. It develops in the subcutaneous and inter-
muscular connective tissues and produces vesicles and abscesses. In the
large majority of the cases the parasite is found in the leg. Of 181 cases,
in 124 the worm was found in the feet, 33 times in the leg, and 11 times in
the thigh. The worm is usually solitary, though there are cases on record
in which six or more have been present. It is cylindrical in form, about
two millimetres in diameter, and from fifty to eighty centimetres in length.
The worm gains entrance to the system through the stomach, not
through the skin, as was formerly supposed. It is probable that both
male and female are ingested ; but the former dies and is discharged,
while the latter after impregnation penetrates the intestine and attains its
full development in the subcutaneous tissues, where it may remain quies-
cent for a long time and can be felt beneath the skin like a bundle of
string. Suppuration is after a time excited, and when the abscesses are
opened or burst the worm appears and is sometimes discharged entire. The
worm contains an enormous number of living embryos, which escape into
the water and develop in the cyclops — a small crustacean — and it seems
likely that man is infected by drinking the water containing these devel-
oped larvne.
* For full considonition of the subject of congeuital occlusion and dilatation of
lymph channels, see work on this subject by Samuel C. Busey, New York, 1878.
DISEASES CAUSED BY NEMATODES. 1035
The treatment consists in promoting the suppuration, and wlicn the
worm is seen the common procedure is to roll it round a portion of smooth
wood, and in this way prevent the retraction, and each day wind a little
more until the entire worm is withdrawn. It is stated that special care
must be taken to prevent tearing of the worm, as disastrous consequences
sometimes follow, probably from the irritation caused by the migration
of the embryos. It is stated that the leaves of the plant called amarpattee
are almost a specific in the disease. Asafoetida in full doses is said to kill
the worm.
VI. Othek Nematodes.
{a) Among less important filarian worms parasitic in man the follow-
ing may be mentioned : filaria loa^ which is a cylindrical worm of about
three centimetres in length and whose habitat is beneath the conjunctiva.
It has been found on the West African coast, in Brazil, and in the West
Indies. Filaria lentis^ which has been found in a cataract. Three speci-
mens have been found together. Filaria lahialis, which has been found
in a pustule in the upper lip Filaria liominis oris, which was described
by Leidy, from the mouth of a child. Filaria bronchialis, which has been
found occasionally in the trachea and bronchi. This parasite has been
seen in a fe'w cases in the bronchioles and in the lungs. There is no evi-
dence that it ever produces an extensive verminous bronchitis similar to
that which I have described in dogs. Filaria imitis, of which Bowlby
has described two cases. In one case with haematuria female worms were
found in the portal vein, and the ova were present in the thickened
bladder wall and in the ureters.
{b) Tricliocephalus Dispar {Whip-ivorm). — This parasite is not infre-
quently found in the caecum and large intestine of man. It measures from
four to five centimetres in length, the male being somewhat shorter than
the female The worm is readily recognized by the remarkable difference
between the anterior and posterior portions. The former, Avhich is at least
three fifths of the body, is extremely thin and hair-like in contrast to the
thick hinder portion of the body, which in the female is conical and
pointed, and in the male more obtuse and usually rolled like a spring.
The ova are, oval, lemon-shaped, -05 millimetre in length, and each is
provided with a button-like projection.
The number of the worms found is variable, as many as a thousand
having been counted. It is a widely spread parasite. In parts of Europe
it occurs in from ten to thirty per cent of all bodies examined, but in this
country it is not so common. The trichocephalus rarely causes symptoms.
It has been thought by certain physicians in the East to be the cause of
beri-beri. Several cases have been reported recently in which profound
anaimia has occurred in connection with this parasite, usually with diar-
rhrea. Enormous numbers may occur, as in Kudolphi's case, without pro-
ducing any symptoms.
1036 DISEASES DUE TO ANIMAL PARASITES.
The diagnosis is readily made by the examination of the faeces, which
contain, sometimes in great abundance, the characteristic lemon-shaped,
hard, dark-brown eggs.
(6*) Eustrougijlus Gigas. — This enormous nematode, the male of which
measures about a foot in length and the female about three feet, occurs in
very many animals and has occasionally been met with in man. It is
usually found in the renal region and may entirely destroy the kidney.
{(l) Rhahdonema Intestinale. — Under this name are now included the
small nematode worms found in the faeces and formerly described as an-
giiilhda stercoralis and anguillula intestinalis. This parasite occurs
abundantly in the stools of the endemic diarrhoea of hot countries, and has
been specially described by the French in the diarrhoea of Cochin-China.
It occurs also in Brazil, and has been found in Italy in connection with
the anchylostoma in cases of miner's anaemia. It is stated that the worms
occupy all parts of the intestines, and have even been found in the biliary
and pancreatic ducts. It is only when they are in very large numbers
that they produce severe diarrhoea and anaemia.
Acanthocephala {Thorn-lieaded Worjns). — The ecliinorhynchus gigas is
a common parasite in the intestine of the hog and attains a large size.
The larvae d(;velop in cockchafer grubs. Lambl found a small echino-
rhynchus in the intestine of a boy. Welch's specimen, which was found
encysted in the intestine of a soldier at Netley, is stated by Cobbold prob-
ably not to have been an ecliinorliynclius. Eecently a case of ecliinorliyn-
chus moniliformis has been described in Italy by Grassi and Calandruccio.
IV. DISEASES CAUSED BY CESTODES
{Tape-worms; Hydatid Disease).
Man harbors the adult parasites in the small intestine, the larval forms
in the muscles and solid organs.
I. Intestinal Cestodes; Tape- worms.
{a) TcBnia solium^ or pork tape-worm. This is not a common form in
this country. It is much more frequent in parts of Europe and Asia.
When mature it is from six to twelve feet in length. The head is small,
round, not so large as the head of a pin, and provided with four sucking
disks and a double row of booklets ; hence it is called, in contradistinction
to the other form in man, the armed tape-worm. To the head succeeds a
narrow, thread-like neck, then the segments, or proglottides, as they are
called. Tlie segments possess both male and female generative organs,
and about the four hundred and fiftieth become mature and contain ripe
ova. ^riie worm attains its full growth in from three to three and a half
months, after which time the segments are continuously shed and appear
DISEASES CAUSED BY CESTODES. 1037
in the stools. The segments are about one centimetre in length and from
seven to eight millimetres in breadth. Pressed between glass plates the
ovarian rosette is seen as a central stem with about twelve or fifteen lateral
branches. There are many thousands of ova in each ripe segment, and
each ovum consists of a firm shell, inside of which is a little embryo, pro-
vided with six booklets. The segments are continuously passed, and if
the ova are to attain further development they must be taken into the
stomach, either of a pig, or of man himself The egg-shells are digested,
the six-hooked embryos become free, and passing from the stomach reach
various parts of the body (the liver, muscles, brain, or eye), where they
develop into the larvae or cysticerci. A hog under these circumstances is
said to be measled^ and the cysticerci are spoken of as measles or blad-
der worms.
The tcenia solium received its name because it was thought to exist as a
solitary parasite in the bowel, but two or three, or even more worms may
occur.
{h) Tcenia saginata or mediocanellata — the unarmed or beef tape-worm.
This is a longer and larger parasite than the tcenia solium. It is certainly
the common tape-worm of this country. Of scores of specimens which I
have examined, almost all were of this variety. According to Berenger-
Feraud it has spread rapidly in western Europe, owing probably to the
importation of beef and live stock from the Mediterranean basin. It may
attain a length of fifteen or twenty feet, or more. The head is large in
comparison to the tcenia soliurn, and measures over two millimetres in
breadth. It is square-shaped and provided with four large sucking disks,
but there are no booklets. The ripe segments are from seventeen to
eighteen millimetres in length, and from eight to ten millimetres in
breadth. The ovarian rosette consists of a central stem with from seven-
teen to eighteen lateral branches, which are given off more dichotomously
than in the tcenia solium. The ova are somewhat larger, and the shell is
thicker, but the two forms can scarcely be distinguished by their ova.
The ripe segments are passed as in the taenia solium, and are ingested by
cattle, in the flesh or organs of which the eggs develop into the bladder
worms or cysticerci. Whether they develop in man or not is uncertain.
No instance of the cysticercus of the tcenia saginata has, so far as I know,
been reported in man.
Of other forms of tape-worm may be mentioned :
(c) Tcenia elliptica {tcenia cucumerina). A small parasite very com-
mon in the dog and occasionally found in man, and the larvae of which de-
velop in the louse of the dog.
(d) Tcenia flavo-punctata. A small cestode was found in the intes-
tine of a child in Boston, and has since been met with in one or two
cases.
(e) Tcenia nana and the tcenia Madagascar iensis have been found only
once or twice.
1038 DISEASES DUE TO ANIMAL PARASITES.
(/) Bothrioceplialiis latiis. A cestode worm found only in certain
districts bordering on the Baltic Sea and in parts of Switzerland. So far
as I know it has not been found in this country except in a few imported
cases. The parasite is large and long, measuring from twenty-five to
thirty feet or more. Its head is different from that of the taenia, as it
possesses two lateral grooves or pits and has no booklets. The larvae
develop in the peritonaeum and muscles of the pike and other fish, and it
has been shown experimentally that they grow into the adult worm when
eaten by man.
Symptoms. — These parasites are found at all ages. They are not
uncommon in children and are occasionally found in sucklings. W. T.
Plant refers to a number of cases in children under two years, and there is
a case in the literature in which it is stated that the tape-worm w^as found
in an infant five days old.
The parasites may cause no disturbance and are rarely dangerous. A
knowledge of the existence of the worm is generally a source of worry and
anxiety ; the patient may have considerable distress and complain of ab-
dominal pains, nausea, and sometimes diarrhoea. Occasionally, the appetite
is ravenous. In women and in nervous patients the constitutional dis-
turbance may be considerable, and we not infrequently see great mental
depression and even hypochondria. Various nervous phenomena, such as
chorea, convulsions, or epilepsy, are believed to be caused by the parasites.
Such effects, however, are very rare.
The diagnosis is never doubtful. The presence of the segments is dis-
tinctive. The ova, too, may be recognized in the stools. It makes but
little difference as to the form of tape-worm, but the ripe segments of the
tcenia saginata are larger and broader, and show differences in the gen-
erative system as already mentioned.
The prophylaxis is most important. Careful attention should be given
to two points. First, all tape-worm segments should be burned. They
should never be thrown into the water-closet or outside. And second, the
meat should be cooked throughout, in which way alone larvae are destroyed.
Possibly it is owing to the fact that in this country pork is, as a rule, better
cooked than beef that the tcBnia saginata is the most common form. Cer-
tainly in the market and at the abattoirs one more commonly sees measly
pork than measly veal. In the examination of a thousand hogs in Mont-
real there were seventy-six instances of cysticerci. The measle is more
readily overlooked in beef than in pork, as in tlie former it has not such
an ojiafjuc wliitc color.
Treatm.ent. — For two days prior to the administration of the reme-
dies the patient should take a very light diet and have the bowels moved
occasionally by a saline cathartic. Tlie practitioner has the choice of a
large number of drugs. As a rule, the male fern acts promptly and well.
The ethereal extract, in two-drachm doses, may be given fasting, and fol-
lowed in the course of a couple of hours by a brisk purgative. This usu-
DISEASES CAUSED DY (M^]STODES. 1039
ally succeeds in bringing away a large portion, but not always the entire
worm.
A combination of the remedies is sometimes very effective. An in-
fusion is made of pomegranate root, half an ounce ; pumpkin seeds, one
ounce ; powdered ergot, a drachm ; and boiling water, ten ounces. To
an emulsion of the male fern (a drachm of ethereal extract), made with
acacia powder, two minims of croton oil are added. The patient should
have had a low diet the previous day and have taken a dose of salts in the
evening. The emulsion and infusion are mixed and taken fasting at nine
in the morning.
The pomegranate root is a very efficient remedy, and may be given as
an infusion of the bark, three ounces of which may be macerated in ten
ounces of water and then reduced to one half by evaporation. The entire
quantity is then taken in divided doses. It occasionally produces colic, but
is a very effective remedy. The active principle of the root, pelletierine, is
now much employed. It is given in doses of one fourth to one half of a
grain, and is followed in an hour by a purge.
Pumpkin seeds are sometimes very efficient. Three or four ounces
should be carefully bruised and then macerated for twelve or fourteen
hours and the entire quantity taken and followed in an hour by a purge.
Of other remedies, koosso, turpentine in ounce doses in honey, and kamala
may be mentioned.
Unless the head is brought away, the parasite continues to grow, and
within a few months the segments again appear. Some instances are ex-
traordinarily obstinate. Doubtless it depends a good deal upon the ex-
posure of the worm. The head and neck may be thoroughly protected
beneath the valvulae conniventes, in which case the remedies may not act.
Owing to its armature the tcenia soUu7n is more difficult to expel. It is
probable that no degree of peristalsis could dislodge the head, and unless
the worm is killed it does not let go its extraordinarily firm hold on the
mucous membrane.
• II. Visceral Cestodes.
Whereas adult taeniae cause little or no disturbance and rarely, if ever,
prove directly fatal, the affections caused by the larvae or immature
forms in the solid organs are serious and important. There are two chief
cestode larvae known to frequent man — (a) the cysticermts celluloscB, the
larva of the tcenia solium, and (b) the ecliinococciis, the larva of the tmnia
ecldnococciis.
I. Cysticercus Cellulosae.— When man accidentally takes into his
stomach the ripe ova of tcenia soliuvi he is liable to become the interme-
diate host, a part usually played for this tape-worm by the pig. This acci-
dent may occur in an individual the subject of tcBuia solium, in which
case the mature proglottides either themselves wander into the stomach
or, what is more likely, are forced into the organ in attacks of prolonged
1040 DISEASES DUE TO ANIMAL PARASITES.
vomiting. -Of course the accidental ingestion from the outside of a few
ova is quite possible, and the liability of infection should always be borne
in mind in handling the segments of the worm.
The symptoms depend entirely upon the number of ova ingested and
the localities reached. In the hog the cysticerci produce very little dis-
turbance. The muscles, the connective tissue, and the brain may be
swarming with the measles, as they are called, and yet the nutrition is
maintained and the animal does not appear to be seriously incommoded. In
the invasion period, if large numbers of the parasites are taken, there is,
in all probability, constitutional disturbance ; certainly there is in the
calf, when fed with the ripe segments of tcBuia saginata.
In man a few cysticerci lodged beneath the skin or in the muscles may
cause no damage, and in time the larvas die and become calcified. They
are occasionally found in dissection subjects or in post-mortems as ovoid
white bodies in the muscles or subcutaneous tissue. In this country they
are very rare. I have seen but one instance in my post-mortem experi-
ence. Depending on the number and the locality specially affected, the
symptoms may be grouped into general, cerebro-spinal, and ocular.
(1) General. — As a rule the invasion of the larvae in man, unless in
very large numbers, does not cause very definite symptoms. It occa-
sionally happens, however, that a striking picture is produced. For in-
stance, a patient was admitted to my wards very stiff and helpless, so
much so that he had to be assisted up-stairs and into bed. He com-
plained of numbness and tingling in the extremities and general weakness,
so that at first he was thought to have a peripheral neuritis. At the ex-
amination, however, a number of painful subcutaneous nodules were dis-
covered, which proved on excision to be the cysticerci. Altogether seventy-
five could be felt subcutaneous^y, and from the soreness and stiffness they
probably existed in large numbers in the muscles. There were none in
his eyes, and he had no symptoms pointing to brain lesions.
(2) Cerebro-sjnnal. — Remarkable symptoms may result from the pres-
ence of the cysticerci in the brain and cord. In the silent region they
may be abundant without producing any symptoms. I have in my pos-
session the brain of a pig containing scores of " measles," yet the animal
in the few moments in which I saw it just prior to death did not pre-
sent any symptoms to attract attention. In the ventricles of the brain the
cysticerci may attain a considerable size, owing to the fact that in regions
in wliich they are unrestrained in their growth the bladder-like body
grows freely, as in the peritoUcTeum. AVlien in the fourtli ventricle re-
markable irritntive symptoms may be produced. In 1884 I saw with
Friedliinder in Berlin a case from Riess's wards in which during life there
had been symptoms of diabetes and anomalous nervous symptoms. Post
mortem, the cysticercus was found beneath the valve of Vieussens, pressing
upon the floor of the left ventricle.
(3) Ocular. — Since von Graefe demonstrated the presence of the cysti-
DISEASES CAUSED BY CE8T0DES. lOM
cercus in the vitreous liumor many cases have been phiced on record, and
it is a condition easily recognized by oculists.
Except in the eye, the diagnosis can rarely be made ; when the cysti-
cerci are subcutaneous, one may be excised. It is possible that when
numerous throughout the muscles they may be seen under the tongue, in
which situation they may exist in the pig in numbers.
II. Echinococcus Disease. — The hydatid worms or echinococci are the
larvae of the tcenia ecliinococcus of the dog. This is a tiny cestode not
more than four or five millimetres in length, consisting of only three or
four segments, of which the terminal one alone is mature, and has a length
of about two millimetres and a breadth of 0-6 millimetre. The head is
small and provided with four sucking disks and a rostellum with a double
row of booklets. This is an exceedingly rare parasite in the dog. Cob-
bold states that he has never met with a natural specimen in England.
Leidy had not one in his large collection. I have not met with an in-
stance in this country, nor do I know of its ever having been described.
The only specimens in my cabinet I procured experimentally by feeding a
dog with echinococcus cysts from an ox. The worms are so small that
they may be readily overlooked, since they form small white, thread-like
bodies closely adherent among the villi of the small intestines. The ripe
segment contains about 5,000 eggs, which attain their development in the
solid organs of various animals, particularly the hog and ox ; more rarely
the horse and the sheep. In some countries man is a common intermedi-
ate host, owing to the accidental ingestion of the ova.
Development. — The little six-hooked embryo, freed from the egg-shell
by digestion, either burrows through the intestinal wall and reaches the
peritoneal cavity or the muscles ; more commonly it enters the portal ves-
sels and is carried to the liver. It may enter the systemic vessels, and,
passing the pulmonary capillaries, as it is protoplasmic and elastic, may
reach the brain or other parts. Once having reached its destination, it
undergoes the following changes : The booklets disappear and the little
embryo is gradually converted into a small cyst which presents two dis-
tinct layers — an external, laminated, cuticular membrane or capsule, and
an internal, granular, parenchymatous layer, the endocyst. The little
cyst or vesicle contains a clear fluid. There is more or less reaction in the
neighboring tissues, and the cyst in time has a fibrous investment. AVhen
this primary cyst or vesicle has attained a cortain size buds develop from
the parenchymatous layer, which are gradually converted into cysts, pre-
senting a structure identical with that of the original cyst, namely, an elastic
chitinous membrane lined with a granular parenchymatous layer. These
secondary or daughter cysts are first connected with the lining membrane
of the primary, but are soon set free. In this way the primary cyst as it
grows may contain a dozen or more daughter cysts. Inside these daughter
cysts a similar process may occur, and from buds in the walls grand-
daughter cysts are developed. From the granular layer of the parent and
10J:2 DISEASES DUE TO ANIMAL PARASITES.
daughter cysts buds arise wliich develop into brood capsules. From the
lining membrane the little outgrowths arise and gradually develop into
bodies known as scolices, which represent in reality the head of the tcenia
echinococcus and present four sucking disks and a circle of booklets.
Each scolex is capable when transferred to the intestines of a dog of de-
veloping into an adult tape- worm. The difference between the ovum of
an ordinary tape-worm, such as the tcenia solium^ and the tcenia echino-
coccus is in this way very striking. In the former case the ovum devel-
ops into a single larva — the cysticerciis cellulosce — whereas the Qgg of the
tcenia ecliinococcus develops into a cyst which is capable of multiplying
enormously and from the lining membrane of which millions of larval
tape-worms develop. Ordinarily in man the development of the echino-
coccus takes place as above mentioned and by an endogenous form in
which the secondary and tertiary cysts are contained within the primary ;
but in animals the formation may be different, as the buds from the pri-
mary cyst penetrate between the layers and develop externally, forming
the exogenous variety. A third form is the multilocular echinococcus, in
which from the primary cysts buds develop which are cut off completely
and are surrounded by thick capsules of a connective tissue, which join
together and ultimately form a hard mass represented by strands of con-
nective tissue enclosing alveolar spaces about the size of peas or a little
larger. In these spaces are found the remnants of the echinococcus cyst,
occasionally the scolices or booklets, but they are often sterile.
The fluid of the echinococcus cysts is clear and limpid, and has a spe-
cific gravity from 1-005 to 1'009. It does not contain albumen, but may con-
tain traces of sugar. As a rule, the cysts, when not degenerated, contain
the hydatid heads or scolices or the characteristic booklets.
Changes in the Cyst. — It is not known definitely how long the echino-
coccus remains alive, but it probably lives many years — according to some
authors as long as twenty years. The most common change is death and
the gradual inspissation of the contents and conversion of the cyst into a
mass containing putty-like or granular material which may be partially
calcified. Remnants of the chitinous cyst wall or booklets may be found.
These obsolete hydatid cysts are not infrequently found in the liver. A
more serious termination is rupture, which may take place into a serous
sac, or perforation may take place externally, when the cysts are discharged,
as into the bronchi or alimentary canal or urinary passages. More unfa-
vorable are the instances in which rupture occurs into the bile-passages or
into the inferior cava. Recovery may follow the rupture and discharge of
tlie hydatids externally. Sudden death has been known to follow the
rupture. A tliird and very serious mode of termination is suppuration,
which may occur spontaneously or follow rupture and is found most fre-
(|U(']itly in tlie liver. Large abscesses may be formed which contain the
hydatid membranes.
Geographical Distribution of the Echinococcus. — The disease prevails
DISEASES CAUSED BY CESTODES. 1043
most extensively in those countries in which man is brought into close
contact with the dog, particularly when, as in Australia, the dogs are used
extensively for herding sheep, the animal in which the larval form of the
tcenia echinococcus is most frequently found. In Iceland the cases are
very numerous. In Europe the disease is not uncommon. In this coun-
try it is extremely rare and a great majority of all cases are in for-
eigners. Up to July, 1891, I have been able to find in the literature
(and in the museums) only 85 cases in the United States and Canada.*
Distribution in the Body. — Of the 1,8G2 cases comprised in the statis-
tics of Davaine, Cobbold, Finsen, and Neisser, the parasites existed in the
liver in 953, in the intestinal canal in 1G3, in the lung or pleura in 153, in
the kidneys, bladder, and genitals in 186, in the brain and spinal canal in
127, bone CI, heart and blood-vessels 61, other organs 158. \ Of the 85
cases in this country, the liver was the seat of the disease in 59. Of 50
consecutive cases treated by Mosler at the Greifswald clinic, 36 involved
the liver, 10 the lungs, 3 the right kidney, and 1 the spleen.
Symptoms. — {a) Hydatids of the Liver. — Small cysts may cause
no disturbance ; large and growing cysts produce signs of tumor of the
liver with great increase in the size of the organ. Naturally the physical
signs depend much upon the situation of the growth. Near the anterior
surface in the epigastric region the tumor may form a distinct prominence
and have a tense, firm feeling, sometimes with fluctuation. A not infre-
quent situation is to the left of the suspensory ligament, forming a tumor
which pushes up the heart and causes an extensive area of dulness in the
lower sternal and left h3rpochrondriac regions. In the right lobe, if the
tumor is on the posterior surface, the enlargement of the organ is chiefly
upward into the pleura and the vertical area of dulness in the posterior
axillary line is increased. Superficial cysts may give what is known as
the hydatid fremitus. If the tumor is palpated lightly with the fingers
of the left hand and percussed at the same time with those of the right
there is felt a vibration or trembling movement which persists for a cer-
tain time. It is not always present, and it is doubtful whether it is pecul-
iar to the hydatid tumors or is due, as Brian9on held, to the collision of
the daughter cysts. Very large cysts are accompanied by feelings of
pressure or dragging in the hepatic region, sometimes actual pain. The
general condition of the patient is at first good and the nutrition little, if
at all, interfered with. Unless some of the accidents already referred to
occur, the symptoms indeed may be trifling and due only to the pressure
or weight of the tumor.
Suppuration of the cyst changes the clinical picture into one of pyaemia.
There are rigors, sweats, more or less jaundice, and rapid loss of weight.
Perforation may occur into the stomach, colon, pleura, bronchi, or exter-
* American Journal of the Medical Sciences, October, 1882. Since that date Alfred
Mann has collected for me 24 cases in addition to the 61 there reported,
f Dictionnaire Encyclopedique des Sciences Medicales, tome 32, 1885.
66
1044 DISEASES DUE TO ANIMAL PARASITES.
nally, and in some instances recovery iias taken place. Perforation into
the pericardium and inferior vena cava is fatal. In the latter case the
daughter cysts have been found in the heart, plugging the tricuspid ori-
fice and the pulmonary artery. Perforation of the bile-passages causes
intense jaundice, and may lead to suppurative cholangitis.
An interesting symptom connected with the rupture of hydatid cysts
is the development of urticaria, which may also follow aspiration of the
cysts and is probably due to the absorption of toxic materials contained in
the fluid.
Diagnosis. — Cysts of moderate size may exist without producing
symptoms. Large multiple echinococci may cause great enlargement with
irregularity of the outline, and such a condition persisting for any time
with retention of the health and strength suggests hydatid disease. An
irregular, painless enlargement, particularly in the left lobe, or the pres-
ence of a large, smooth fluctuating tumor of the epigastric region is also
very suggestive, and in this situation, when accessible to palpation, it
gives a sensation of a smooth elastic growth and possibly also the hydatid
tremor. When suppuration occurs the clinical picture is really that of
abscess and only the existence of previous enlargement of the liver with
good health would point to the fact that the suppuration was associated
with hydatids. Syphilis may produce irregular enlargement without much
disturbance in the health, sometimes also a very definite tumor in the
epigastric region, but it is usually firm and not fluctuating. The clinical
features may simulate cancer very closely. In a case which I reported
the liver was greatly enlarged and there w^ere many nodular tumors
in the abdomen. The post-mortem showed enormous suppurating hy-
datid cysts in the left lobe of the liver which had perforated the
stomach in two places and also the duodenum. The omentum, mes-
entery, and pelvis also contained numerous cysts. As a rule, the
clinical course of the disease would suffice to separate it clearly from can-
cer. Dilatation of the gall-bladder and hydronephrosis have both been
mistaken for hydatid disease. In the former the movable character of
the tumor, its shape, and the mucoid character of the contents suffice for
the diagnosis. In some instances of hydronephrosis only the exploratory
puncture could distinguish between the conditions. More frequent is tlie
mistake of confounding a hydatid cyst of the right lobe pushing up the
pleura with pleural effusion of the right side. The heart may be dislo-
cated, the liver depressed, and dulness, feeble breathing, and diminished
fremitus are present in both conditions. Frerichs lays stress upon the
different character of the line of dulness; in the echinococcus cyst the
upper limit presents a curved line, the maximum of which is usually in
the scapular region. Suppurative pleurisy may be caused by the perfora-
tion of the cyst. If adhesions result, the perforation takes place into the
lung, and fragments of the cysts or small daughter cysts may be coughed up.
For diagnostic purposes the ex})loratory puncture should be used. As
DISEASES CAUSED BY CESTODES. 1045
stated, the fluid is usually perfectly clear or slightly oi)alescent, the reaction
is neutral, and the specific gravity varies from 1*005 to 1*009. It is non-
albuminous, but contains chlorides and sometimes traces of sugar. Ilook-
lets may be found either in the clear fluid or in the suppurating cysts.
They are sometimes absent, however, as the cyst may be sterile.
{b) Echinococcus of the Rcspiratoi^y System. — The larvas may develop
primarily in the pleura and attain a large size. The symptoms are at first
those of compression of the lung and dislocation of the heart. The physi-
cal signs are those of fluid in the pleura and the condition could scarcely
be distinguished from ordinary effusion. The line of dulness may be quite
irregular. As in the echinococcus of the liver, the general condition of
the patient may be excellent in spite of the existence of extensive disease.
Pleurisy is rarely excited. The cysts may become inflamed and perforate
the chest wall. In a case of D. F. Smith's, of Walkertown, Ontario, a
girl, aged twenty, had a running sore in the eighth left intercostal space.
This was freely opened, and in the pus which flowed out were a number of
well-characterized echinococcus cysts of various size. The patient re-
covered.
Echinococci occur more frequently in the lung than in the pleura. If
small, they may exist for some time without causing serious symptoms.
In their growth they compress the lung and sooner or later lead to inflam-
matory processes, often to gangrene, and the formation of cavities which
connect with the bronchi. Fragments of membrane or small cysts may be
expectorated. Haemorrhage is not infrequent. Perforation into the pleura
with empyema is common. A majority of the cases are regarded during
life as either phthisis or gangrene, and it is only the detection of the char-
acteristic membranes or the booklets which leads to the diagnosis. The
condition is usually fatal ; only a few cases have recovered. Of the 85
American cases, in six the cysts occurred in the lung or pleura.
(c) Echinococcus of the Kidneys. — In the collected statistics referred
to above the genito-urinary system comes second as the seat of hydatid
disease, though it is rare in comparison wdth the affection of the liver. Of
the 85 American cases, there were only three in which the kidneys or blad-
der were involved. The kidney may be converted into an enormous cyst
resembling hydronephrosis.
The diagnosis is only possible by puncture and examination of the
fluid. The cyst m_ay perforate into the pelvis of the kidney and portions
of the membrane or cysts may be discharged with the urine, sometimes
producing renal colic. I have reported a case in which for many months
the patient passed at intervals numbers of small cysts with the urine.
The general health was little if at all disturbed, except by the attacks of
colic during the passage of the parasites.
{d) Echinococcus of the Nervous System. — In this country very few
instances have occurred in the brain. One or two reports indicate clearly
that the common cystic disease of the choroidal plexuses has been mis-
1046 DISEASES DUE TO ANIMAL PARASITES.
taken for hydatids. Davies Thomas, of Australia, has tabulated 97 cases,
including some of the cysticercus cellulosm. According to his statistics,
the cyst is more common on the right than on the left side, and is most
frequent in the cerebrum.
The symptoms are very indefinite, as a rule, being those of tumor.
Persistent headache, convulsions, either limited or general, and gradually
developing blindness have been prominent features in many cases.
Multilocular Echiuococcus. — This form merits a brief separate descrip-
tion, as it differs so remarkably from the usual type of the disease. About
one hundred instances are on record, the great majority of which have oc-
curred in Bavaria and in Switzerland. Only one case has been reported
in the United States.* The patient was a German, who had been in the
country five years. For a year previous to his death he was out of health,
jaundiced, and somewhat emaciated. A fluctuating tumor was found in
the right lumbar and umbilical regions, apparently connected with the
liver. This was opened, and death followed from haemorrhage. About
a fourth of the right lobe of the liver was occupied by an irregular cavity
with rough, ragged walls, which in places were from one to two inches in
thickness and enclosed irregular small cavities. The lamellated cuticula
charactsristic of the echiuococcus cyst was found lining these cavities. In
some instances the tumor bears a striking likeness to colloid cancer, as on
section it presents a fibrous stroma with cavities containing gelatinous
material. They are often sterile — that is, without the hydatid heads or
larvae. This form is almost exclusively confined to the liver, and the
symptoms resemble more those of tumor or cirrhosis. The liver is, as a
rule, enlarged and smooth, not irregular as in the ordinary echiuococcus.
Jaundice is a common symptom. The spleen is usually enlarged, there
is progressive emaciation, and toward the close haemorrhages are com-
mon.
Treatment of Echinococcus Disease. — Medicines are of no
avail. Post-mortem reports show that in a considerable number of cases
the parasite dies and the cyst becomes harmless. Operative measures
should be resorted to when the cyst is large or troublesome. The simple
aspiration of the contents has been successful in a large number of cases,
and as it is not in any way dangerous, it may be tried before the more
radical procedure of incision and evacuation of the cysts. Suppuration
has occasionally followed the puncture. Injections into the sac should
not be practised. With modern methods surgeons now open and evacuate
the echinococcus cysts with great boldness, and the Australian records,
which are the most numerous and important on this subject, show that
recovery is the rule in a large proportion of the cases. Suppurative cysts
in the liver should be treated as abscess. Naturally the outlook is less
favorable. The practical treatment of hydatid disease has been greatly
* Delafit'ld .'111(1 Prudden, Pulhological Anatomy, third edition, page 317.
PARASITIC AUACIINIDA. 1047
advanced by Australian surgeons. The recent work of James Graliarn, of
Sydney, may be consulted for interesting details in diagnosis and treat-
ment.
V. PARASITIC ARACHNIDA.
(1) Pentastomes. — {a) The pentastomuin tmnioides has a somewhat
lancet-shaped body, the female from three to four inches in length, the
male about an inch in length. The body is tapering and marked by
numerous rings. The adult worm infests the frontal sinuses and nostrils
of the dog, more rarely of the horse. The larval form, which is known as
the pentastomitm denticidatum^ is found in the internal organs, particu-
larly the liver, but has also been found in the kidney. The adult worm
has been found in the nostril of man, but is very rare and seldom occa-
sions any inconvenience. The larvae are by no means uncommon, par-
ticularly in parts of Germany.
{b) The pentastomum constrictum^ which is about the length of half
an inch, with twenty-three rings on the abdomen, was found by Aitken in
the liver and lungs of a soldier of a West Indian regiment.
The only case of pentastomes which, so far as I know, has been re-
ported in this country is the one referred to in Flint's Practice of Medi-
cine. From 75 to 100 of the parasites were expectorated. The liver was
enlarged and the parasites probably occupied this region. In 18G9 I saw
a specimen which had been passed in the urine by a patient of James 11.
Richardson, of Toronto.
(2) Demodex (Acarus) Folliculorum. — A minute parasite, from 03
millimetre to 0-4 millimetre in length, which lives in the sebaceous folli-
cles, particularly of the face. It is doubtful whether it produces any
symptoms. Possibly when in large numbers they may excite inflamma-
tion of the follicles, leading to acne.
(3) Acarus (or Sarcoptes) Scabiei (Itch Insect).— Th\^ is the most
important of the arachnid parasites, as it produces troublesome and dis-
tressing skin eruptions. The male is -23 millimetre in length, and -19 mil-
limetre in breadth ; the female is 0*45 millimetre in length and 0*35 milli-
metre in width. The female can be seen readily with the naked eye and
has a pearly-white color. It is not so common a parasite in the United
States and Canada as in Europe.
The insect lives in a small burrow, about one centimetre in length,
whicli it makes for itself in the epidermis. At the end of this burrow the
female lives. The male is seldom found. The chief seat of the parasite
is in the folds where the skin is most delicate, as in the web between the
fingers and toes, the backs of the hands, the axilla, and the front of the
abdomen. The head and face are rarely involved. The lesions which re-
sult from the presence of the itch insect are very numerous and result
largely from the irritation of the scratching. The commonest is a papular
1048 DISEASES DUE TO AXIMAL PARASITES.
and vesicular rash or, in children, an ecthymatous eruption. The irrita-
tion and pustulation which follow the scratching may completely destroy
the burrows, but in typical cases there is rarely any doubt as to the diag-
nosis.
The treatment is simple. It should consist of warm baths with a thor-
ough use of a soft soap, after which the skin should be anointed with
sulphur ointment, which in the case of children should be diluted. An
ointment of naphthol (drachm to the ounce) is very efficacious.
(4) Leptus Autumnalis {Harvest Bug). — This reddish-colored para-
site, about one half millimetre in size, is often found in large numbers in
fields and in gardens. They attach themselves to animals and man with
their sharp proboscides, and the booklets of their legs produce a great deal
of irritation. They are most frequently found on the legs. They are
readily destroyed by sulphur ointment or corrosive-sublimate lotions.
Several varieties of ticks are occasionally found on man — the Ixodes
ricinus and the Ixodes americanus, which are met with in liorses and oxen.
VI. PARASITIC INSECTS.
(1) FQ&iQVili {Phthii'iasis ; Pediculosis). — There are three varieties of
the body louse, which are found only in persons of uncleanly habits.
Pediculus Capitis. — The male is from 1 to 1-5 millimetre in length
and the female nearly 2 millimetres in length. The color varies some-
what with the different races of men. It is light gray with a black mar-
gin in the European, and very much darker in the negro and Chinese.
Tliey are oviparous, and the female lays about sixty eggs, which mature in
a week. The ova are attached to the hairs, and can be readily seen as
white specks, known popularly as nits. The symptoms are irritation and
itching of the scalp. When numerous they may excite an eczema or a
pustular dermatitis, which causes crusts and scabs, particularly at the back
of the head. In the most extreme cases the hair becomes tangled in these
crusts and matted together, forming at the occiput a firm mass which is
known as plica polonica., as it was not infrequent among the Jewish in-
habitants of Poland.
Pediculus Corporis ( Vestimentortim). — This is considerably larger
than the head louse. It lives on the clothing and in sucking the blood
causes minute haemorrhagic specks, which are very common about the
neck, back, and abdomen. The irritation of the bites may cause urticaria,
and the scratching is usually in linear lines. In long-standing cases, par-
ticularly in tlio old dissipated characters, the skin becomes rough and
greatly pigmented, a condition which has been termed the vagabond's dis-
ease— morbus errorum — and wliich may be mistaken for the bronzing of
Addison\s disease.
Pediculus pubis dillers soniewiiat from tlic other forms, and is found
TARASITIC INSECTS. 1049
in the parts of the body covered with short hairs, as the pubes; more
rarely the axilla and eyebrows.
The taches Ueudtres are stated by French writers to be excited by the
irritation of pediculi. They are certainly associated with them in a con-
siderable number of cases, but, if really caused by these parasites, it is diffi-
cult to understand why they should only be present with fever.
Treatment. — For the pediculus capitis^ when the condition is very
bad, the hair should be cut short, as it is very difficult to destroy thor-
oughly all the nits. Repeated saturations of the hair in coal oil or in
turpentine are usually efficacious, or with lotions of carbolic acid, one to
fifty. Scrupulous cleanliness and care are sufficient to prevent recurrence.
In the case of the jjediculus corporis the clothing should be placed for
several hours in a disinfecting oven. To allay the itching a warm bath
containing four or five ounces of bicarbonate of soda is useful. The skin
may be rubbed with a lotion of carbolic acid, two drachms to the pint,
with two ounces of glycerin. For the pediculus pubis white precipi-
tate or ordinary mercurial ointment should be used, and the parts should
be thoroughly washed two or three times a day with soft soap and water.
(2) Cimex Lectularius {Common Bed-bug). — This parasite is from three
to four millimetres in length and has a reddish-brown color. It lives in the
crevices of the bedstead and in the cracks in the floor and in the walls. It
is nocturnal in its habits. The peculiar odor of the insect is caused by the
secretion of a special gland. The parasite possesses a long proboscis, with
which it sucks the blood. Individuals differ remarkably in the reaction
to the bite of this insect ; some are not disturbed in the slightest by them,
in others the irritation causes hypersemia and often intense urticaria.
Thorough fumigation with sulphur or scouring with corrosive-sublimate
solution destroys them.
(3) Pulex Irritans {The Common Flea). — The male is from 2 to 2-5
millimetres in length, the female from 3 to 4 millimetres. The flea
is a transient parasite on man. The bite causes a circular red spot of
hyperaemia in the centre of which is a little speck where the boring appa-
ratus has entered. The amount of irritation caused by the bite is variable.
Many persons suffer intensely and a diffuse erythema or an irritable
urticaria develops ; others suffer no inconvenience whatever.
The pulex penetrans {sand-flea; jigger) is found in tropical coun-
tries, particularly in the AVest Indies and South America. It is much
smaller than the common flea, and not only penetrates the skin, but bur-
rows and produces an inflammation with pustular or vesicular swelling.
It most frequently attacks the feet. It is readily removed with a needle.
Where they exist in large numbers the essential oils are used on the feet
as a preventive.
1050 DISEASES DUE TO ANIMAL PARASITES.
VII. PSEUDO-PARASITES (Myiasis).
Of these, the most important are the larvae of certain diptera, particu-
larly the flesh flies — creophila. The condition is called myiasis.
The most common form is that in which an external wound becomes
living^ as it is called. This myiasis vulnerum is caused by the larvae of
either the blue-bottle or the common flesh fly. The larvag can be removed
readily with the forceps ; if there is any difficulty, thorough cleansing and
the application of an antiseptic bandage is sufficient to kill them. The
ova of these flies may be deposited in the nostrils, the ears, or the con-
junctiva— the myiasis narium, aurium, conjunctivae. This invasion rarely
takes place unless these regions are the seat of disease. In the nose and
in the ear the larvae may cause serious inflammation.
The cutaneous myiasis may be caused by the larvae of the miisca vomi-
toria, but more commonly by the bot-flies of the ox and sheep, which
occasionally attack man. This condition is rare in temperate climates.
Matas has described a case in which oestrus larvae were found in the glu-
teal region. In parts of Central America the eggs of another bot-fly, the
dermatohia^ are not infrequently deposited in the skin and produce a
swelling very like the ordinary boil.
Myiasis interna may result from the swallowing of the larvae of the com-
mon house fly or of species of the genus antliomyia. There are many
cases on record in which the larvae of the mitsca domestica have been dis-
charged by vomiting. Instances in which dipterous larvae have been
passed in the faeces are less common. Finlayson, of Glasgow, has recently
reported an interesting case in a physician, who, after protracted consti-
pation and pain in the back and sides, passed large numbers of the larvae
of the flower fly — anthomyia cmiicularis. Among other forms of larvae or
gentles, as they are sometimes called, which have been found in the faeces
are those of the common house fly, the blue-bottle fly, and the techomyza
fusca. The larvae of other insects are extremely rare. It is stated that
the caterpillar of the tabby moth has been found in the faeces.
Here may be mentioned among the effects of insects the remarkable
urticaria epidemica, which is caused in some districts by the procession
caterpillars, particularly the species cnethocampa. There are districts in
the Kahlberger Schweiz which have been rendered almost uninhabitable
by the irritative skin eruptions caused by the presence of these insects, the
action of which is not necessarily in consequence of actual contact with
them.
IJSTDEX.
Abasia, 986.
Abdomen in typhoid fever, 22.
Abdominal typhus, 1.
Abducens nerve (see Sixth Nerve), 793.
Aberrant, thyroid glands, 712 ; adrenals, 770.
Abortion, in chorea, 931 ; in relapsing fever,
45 ; in small-pox, 56 ; in syphilis, 180.
Abscess, of brain, 903; in appendicitis, 407 ; in
glanders, 260 ; in typhus, 42 ; of kidney (pyo-
nephrosis), 758; of liver, 446; of lung, 552;
of mediastinum, 579; of parotid gland, 328;
of tonsils, 334 ; perinephric, 773 ; pyasmic,
116 ; retroperitoneal, 408 ; retropharyngeal in
cervical caries, 332, 851.
Acanthocephala, 1036.
Acardia, 659.
Acarus, scabiei, 1047 ; folliculorum, 1047.
Accentuated second sound, in chronic Bright's
disease, 753 ; in arterio-sclerosis, 668.
Accessory spasm, 810.
Acephalocysts (see Hydatid Cysts), 1041.
Acetona^mia, 301.
Acetone, 299 ; test for (Le Nobel's), 299.
Acetonuria, 736.
Achondroplasy, 308.
Achromatopsia in hysteria, 972; hemiachro-
matopsia, 787.
Acid, free, in gastric-juice, tests for, 345.
Acne, from iodide of potassium, 956 ; rosacea,
1003.
Acromegalia, 991.
Actinomyces or ray fungus, 261.
Actinomycosis, 261.
Acupuncture, in dropsy, 745 ; in lumbago, 282 ;
in sciatica, 820.
Acute bulbar paralysis, 860.
Acute tuberculosis, 197.
Acute yellow atrophy, 426.
Addison's, disease, 708; pill, 183; keloid, 993.
Ad6nie, 704.
Adenitis in scarlet fever, 73.
Adenitis, tuberculous, 205.
Adenoid growths in pharynx, 335.
Adeno-typhoid (Malta fever), 267.
Adliorcnt peri(;ardium, 589.
Adirondack Mouutaiua for tuberculosis, 251.
Adrenals in Addison's disease, 709.
^gophony, 520, 562.
Age, influence of, in tuberculosis, 192.
Ageusia, 805.
Agraphia, 901.
Ague, 147.
Ague cake (see Enlarged Spleen), 154.
Ainhum, 994.
" Air-hunger" in diabetes, 301.
Air, impure, influence in tuberculosis, 194.
Albini, nodules of, 660.
Albinism, in leprosy (lepra alba), 258 ; of the
lung, 546.
Albumen, tests for, 727.
Albuminuria, 725 ; and life assurance, 729 ;
cyclic, 726; febrile, 726; functional, 726;
in acute Bright's disease, 742 ; in chronic
Bright's disease, 752; in diabetes, 299; in
diphtheria, 106 ; in epilepsy, 952 ; in ery-
sipelas, 113; in gout, 293; in pneumonia,
521 ; in scarlet fever, 70, 72 ; in typhoid fever,
26 ; in variola, 55 ; neurotic, 727 ; physio-
logical, 726 ; prognosis in, 728.
Albuminous expectoration in pleurisy, 570.
Albuminuric retinitis, 784.
Albumose in cultures of tubercle bacilli, 186.
Alcaptonuria, 737.
Alcohol, eff'ects of, on the digestive system,
1002; on the kidneys, 1003; on the nervous
system, 1002 ; poisonous eff'ects of, 1001.
Alcoholic neuritis, 778.
Alcoholism, 1001 ; acute, 1001 ; and tubercu-
losis, 1003 ; chronic, 1001 ; treatment of, 1004.
Alexia, 901.
Algid form of malaria, 153.
Alimentary canal, tuberculosis of, 239.
Alkaloids, putrefactive, 1012.
Allantiasis, 1013.
Allocheiria, 844.
Allorrythmia, 650.
Alopecia, 168.
Altitude in tuberculosis, 185, 251.
Altitude, effects of high, 268.
Amaurosis, hysterical, 785 ; toxic, 785 ; ursa-
mic, 754; in hajmatemesis, 387.
Amblyopia, 785 ; crossed, 789.
1052
INDEX.
Ambulatory typhoid fever, 28.
Amoeba coli (amasbadyscntcriai), 132; in liver
abscess, 132 ; in sputa, 138.
Amoebic dysentery, 132.
Ammouiacal decomposition of urine, 735.
Ammoniaemia, 738, 761.
Amnesia; auditory, 901; visual, 900.
Amphoric breathing, 227, 576.
Amphoric echo, 227.
Amyloid disease, in phthisis, 218; in syphilis,
169 ; of kidney, 757 ; of liver, 456.
Amyotrophic lateral sclerosis, 857, 859.
Antemia, 684 ; in anchylostomiasis, 1032 ; from
Bilharzia, 1024 ; from gastric atrophy, 354 ;
from hiemorrhage, 684 ; from inanition, 686 ;
from lead, 1008 ; idiopathic, 689 ; in gastric
cancer, 381 ; in gastric ulcer, 372 ; mountain,
268 ; in rheumatism, 272 ; in syphilis, 168 ; in
typhoid fever, 17 ; primary or essential, 686 ;
chlorosis, 686 ; progressive pernicious, 689 ;
secondary or symptomatic, 684 ; toxic, 686.
Anaemic murmurs (see II^mic Murmurs).
Anaesthesia, dolorosa, 851 ; in chorea, 937 ; in
hemiplegia, 875 ; in hysteria, 971 ; in lepro-
sy, 259 ; in locomotor ataxia, 843 ; in Mor-
van's disease, 850 ; in railway spine, 983 ; in
unilateral lesions of the cord, 854.
Analgesia, in hysteria, 971 ; in Morvan's dis-
ease, 850 ; in syringo-myelia, 850.
Anarthria, 898.
Anasarca (see Dropsy).
Anchylostomiasis, 1031.
Anchylostomum duodenale, 1031.
Aneurism, 670 ; arte rio- venous, 670, 682 ; cir-
soid, 670 ; cylindrical, 670 ; dissecting, 670 ;
embolic, 671 ; etiology of, 670 ; false, 670 ;
fusiform, 670 ; mycotic, 671 ; of the abdomi-
nal aorta, 680; of the branches of the ab-
dominal aorta, 681 ; of the cerebral arteries,
883 ; of the coeliac axis, 681 ; of heart, 646 ; of
the hepatic artery, 682 ; of the renal artery,
682 ; of the splenic artery, 681 ; of the supe-
rior mesenteric artery, 682; of pulmonary
artery, 217.
Aneurism, of thoracic aorta, 671 ; cough in, 675 ;
diagnosis of, 675 ; dyspnoea in, 675 ; hajmor-
rhage in, 675 ; pain in, 675 ; physical signs
of, 673 ; symptoms of, 672; treatment of, 678 ;
Tufnell's treatment of, 678 ; unilateral sweat-
ing in, 676.
Aneurism, time, 670; verminous, in the horse,
671, 1031.
Angina pectoris, 655 ; pseudo- or hysterical,
657 ; vaao-motoria, 656.
Angina, Ludovici, 332 ; simplex, 330 ; suffoca-
tiva, 99.
Angio-neurotic oedema, 989; heredity in, 989;
recurring colic in, 990.
Angio-sclcrosis, 667.
Anguillula stercoralis, A. intestinalis, 1036.
Animal lymph, 64.
Anisocoria, 792.
Ankle clonus, in hysterical paraplegia, 839,
970 ; in spastic paraplegia, 838 ; spurious, 969.
Anorexia nervosa, 973.
Anosmia, 783.
Ano-vesical centre, 855.
Anterior crural nerve, paralysis of, 817.
Anterior cerebral artery, embolism of, 881.
Anthomya canicularis, 1050.
Anthracosis, of lungs, 553 ; of liver, 440.
Anthrax, 156 ; bacillus, 156 ; in animals, 156.
Antiperistalsis, 362.
Antipneumotoxin, 514.
Antiseptic medication in typhoid fever, 36.
Anuria, complete, 717.
Anus, imperforate, 415.
Aorta, aneurism of, 671 ; dynamic pulsation of,
677 , throbbing, 980 ; hypoplasia of m chlo-
rosis, 687 ; tuberculosis of, 246.
Aortic incompetency, 602; sudden death in,
607 ; symptoms of, 604.
Aortic orilice, congenital lesions of, 661 ; size
of, 603.
Aortic stenosis, 608.
Aortic valves, bicuspid, condition of, 660 ;
relative insufficiency of, 603.
Apex of lung, catarrh of, 231 ; puckering of,
249 ; in tuberculosis, 214.
Apex pneumonia, 522, 525.
Aphasia, 898; anatomical localization of, 902;
ataxic, 901 ; hemiplegia witli, 901 ; in in-
fantile hemiplegia, 908; mixed forms of.
902; motor, 901; of conduction, 902; in
phthisis, 229; prognosis of, 903; sensory,
899 ; in typhoid fever, 25 ; tests for, 902 ;
transient, in nngraine, 958; Wernicke's, 902.
Ai)hemia (see Aphasia).
x\phunia, hysterical, 972; in acute laryngitis,
480 ; in adductor paralysis, 807 ; in pericar-
dical eflfusion, 585.
Aphthffi (see Stomatitis, aphthous), 323.
Apoplectic habitus^ 870.
Apoplexy, cerebral, 870; ingravescent, 873;
pulmonary, 508.
Apparitions in migraine, 957.
Appendicitis, 405, 406; catarrhal, 407, 409;
perforative, 407, 409 ; ulcerative, 407.
Appendix vermiformis, situation of, 406; per-
foration of, in typhoid fever, 7.
Aprosexia, 335, 338.
Arachnida, parasitic, 1047.
Arachnitis (see Meningitis), 863,
Aran-DucTienne type of muscular atrophy,
857 ; in lead-poisoning, 1010.
Arch of aorta, aneurism of, 672.
Arcus senilis, 644.
Argyll- Robertson pupil, 792; in ataxia, 842.
INDEX.
1053
Ann, peripheral paralysis of (sec Paralysis of
Brachial Plexus).
Arrythmia, C)^>0.
Arsenical neuritis, 770.
Arsenical pigmentation, 1011 ; in eliorea, 938.
Arsenical poisoning, 1011 ; paralysis in, 1012.
Arteries, diseases of, 6G3 ; calcification of, (K)3 ;
degeneration of, 6()3 ; fatty, 603; liyaline,
664 ; tuberculosis of, 246.
Arterio-capillary fibrosis, 664.
Arterio-sclerosis, 664; diffuse, 666; in lead-
poisoning, 1010; in migraine, 958 ; nodular
form, 665 ; in phthisis, 233 ; senile form, 666 ;
symptoms of, 668 ; treatment of, 669.
Arteritis in typlioid fever, 9.
Arteritis, syphilitic, 178.
x\rthralgia from lead, 1010.
Arthritis, 275 ; acute, in infants, 276 ; gonor-
rhoea!, 280 ; ill acute myelitis, 829 ; in cerebro-
spinal meningitis, 96 ; in dengue, 91 ; in
dysentery, 137 ; in diphtheria, 106 ; in haemo-
philia, 321 ; in tabes dorsalis, 844; multiple
secondary, 275 ; in purpura, 317 ; rheumatoid,
282 ; in scarlet fever, 72 ; septic, 275.
Arthritis deformans, 282 ; chronic form, 285 ;
general progressive form, 284; Ileherden'-s
nodosities in, 284; partial or mono-articular
form, 286.
Arthropathies in tabes, 844.
Ascariasis, 1025.
Ascaris lurabricoides, 1025.
Ascites, 469; chylous, 471; from cancerous
peritonitis, 469 ; from ciri'hosis of the liver,
443 ; from syphilis of the liver, 177 ; in cancer
of the liver, 454; in tuberculous peritonitis,
238; physical signs of, 470; treatment of, 473.
Ascitic fluid ; chylous, 471 ; serous, 471 ;
haemorrhagic, 471.
Aspect, facial ; in typhoid fever, 13; in pneu-
monia, 517; in hereditary lues, 171 ; in pa-
ralysis agitans, 927.
Aspergillus in lung, 222.
Asphyxia, local, 987 ; in diphtlieria, 105 ; death
by, in phthisis, 234.
Aspiration, JiowdUch''s conclusions on, 570 ;
in empyema, 571 ; in pericardial effusion,
589; in pleuritic effusion, 569; tuberculosis
after, 194.
Aspiration pneumonia, 537.
Astasia-abasia, 986.
Asthma, bronchial, 497 ; etiology of, 497 ; nasal
affections in, 498; sputum in, 499; symptoms
of, 499 ; treatment of, 500 ; cardiac, 497 ; hay,
477; LojjfhTL'H crystals in, 500; renal, 497;
thymic, 580.
Atavism, in huiinophilia, 320 ; in gout, 2^7.
Ataxia, cerebellar, 921 ; hereditary, 848 ; in
peripheral neuritis^ 779; in progressive pare-
sis, 917 ; locomotor, 840; after small-pox, 55.
Ataxic gait, 843.
Ataxic paraplegia, 839.
Atelectasis, i)ulmonary, 537.
Atheroma (see Aktekio-sclerosis and PnLEP.o-
SCLEROSIS).
Athetosis, 908 ; bilateral or double, 910.
Athlete's heart, 602.
Atroi)hy, idiopathic muscular, 996; of brain,
dirtuse, in general paresis, 915; of brain,
unilateral, 907 ; of nmscles, various forms of,
996; progressive muscular, of spinal origin,
857 ; unilateral, of face, 990.
Attitude, in pseudo-hypertrophic muscular
paralysis, 996 ; in paralysis agitans, 927.
Auditory centre, affections of, 801 ; nerve,
diseases of, 801 ; vertigo, 803.
Aura, forms of, in epilepsy, 950.
Auto-infection in tuberculosis, 198.
Automatism, in petit mal^ 952 ; in cerebral
syphilis, 173.
Autumnal fever, 3.
Avian tuberculosis, 184.
Bacillus, anthracis, 156; of cholera, 119.
Bacillus coll communis — distinction from
typhoid bacillus, 3 ; in bile-passages, 435; in
fieces of sucklings, 391, 392; in fat necrosis
with colitis, 459 ; in peritonitis, 463 ; in sup-
purative ependymitis, 865; in cancrum oris,
326.
Bacillus diphtheria?, 100 ; attenuated form, 101 ;
value of, in diagnosis, 108.
Bacillus, gastricus, 351 ; of glanders, 259 ; of
smegma, 165; in whooping-cough, 84; ma-
laria}, 142; of leprosy, 258; of syphilis, 1()5;
of tetanus, 163 ; parotitis, 82 ; strepto-, in
typhus fever, 40.
Bacillus tuberculosis, 186; diagnostic value of,
230; distribution of, 186; in sputum, 220;
methods of detection, 221 ; products of growth
of, 186.
Bacillus typhosus, 3.
Bacteria, proteus group in diarrhoea, 392; rela-
tion to diarrhoea, 391, 393.
Bacterium coli commune (see Bacillus Coli
Communis) ; lactis aerogenes, 391.
Balanitis in diabetes, 300.
Ball-thrombus in left auricle, 616.
BantitKfH method in obesity, 1020.
" Barben cholera," 1015.
Barrel-shaped chest in emphysema, 546, 548.
Ii(i^p<low''H disease, 712.
Basilar artery, embolism and thrombosis of,
880.
Baths, cold, in typhoid fever, 34 ; in hyperpy-
rexia of rheumatism, 277; in scarlet fever,
75.
Beaded ribs in rickets, 309.
Bed-bug, 1049.
1054
INDEX
Bed-sores, acute, 829 ; in parai^lcgia, 830.
Beer-drinkers, heart disease in, 639.
BeWs {Luther) mania, 924.
BeWs palsy, V97.
Beri-beri, 780 ; in Japan, 730 ; in the United
States, 780.
"Big-jaw" in cattle, 2G1.
Bile coloring matter, tests for, 424.
Bile-ducts, ascarides in, 437 ; cancer of, 437,
453 ; stenosis of, 437.
Bilipus remittent fever, 151.
Bilharzia liajuiatobia, 1024.
Biliary colic, 432.
Biliary fistulae, 436.
Birth palsies, 909.
Black vomit, 126.
Black spit of miners, 555.
Bladder, paralysis of, in locomotor ataxia, 844 ;
care of in myelitis, 833 ; hypertrophy of,
in diabetes insipidus, 306.
"Bleeders," 321.
Bleeding, in arterio-sclerosis, 670 ; in cerebral
haemorrhage, 882 ; in emphysema, 549 ; in
heart-disease, 624 ; in pneumonia, 530 ; in
sunstroke, 1019 ; in yellow fever, 129.
Blepharospasm, 800.
Blood and ductless glands, diseases of, 684.
Blood-casts (see Casts).
Blood, characters of, in anaemia, 684; in cancer
of the stomach, 381 ; in chlorosis, 687 ; in
cholera, 121 ; in diabetes, 297 ; in gout, 288 ;
in haemophilia, 321 ; in leukaemia, 699 ; in
pernicious anaemia, 692; in pseudo-leukae-
mia, Hodgkin's disease, 706 ; in purpura,
319 ; in secondary anaemia, 684.
Blood-vessels, affections of, 825.
"Blue disease," 662.
Blue line on gums in lead poisoning, 1008.
Boils, in diabetes, 300 ; after small-pox, 55.
Bones, lesions of, in acromegalia, 992 ; in con-
genital syphilis, 171 ; in leukaemia, 702 ; in
rickets, 308 ; in typhoid fever, 27.
Borborygmi, 362.
Bothriocephalus latus, 1038.
Botulism, 1013.
Botyroid liver in sypliilis, 177.
Bovine tuberculosis, 184.
Bowel, affections of (see Intestines) ; infarc-
tion of, 404.
Brachial plexus, affoctions of, 814.
Brachycardia (Bradycardia), 653.
Brain, diseases of, 862; abscess of, 903; anaemia
of, 868 ; atrophy and sclerosis of, 907 ; con-
gestion of, 867 ; cortical centres of, 889 ; cysts
in, 919; diseiwes of substance of, 887; echi-
nococcus of, 1045 ; foci of sclerosis in syphilis,
172; glioma of, 918; hypcraemia of, 867; in-
flammation of, 903; oedema of, 869; poren-
cephalutf of, 907.
Brain, sclerosis of, 911; diffuse, 912; insular,
913; miliary, 912; tuberous, 913.
Brain, softening of, red, yellow, and white, 878,
879.
Brain, tubercle of, 242, 918.
Brain, tumors of, 918; medical treatment of,
922 ; surgical treatment of, 922 ; symptoms,
general and localizing, 919.
Brain-murmur in rickets, 310.
Brand's method in typhoid fever, 34.
Breakbone fever (see Dengue), 90.
Breast-pang, 655.
Breath, odor of, in diabetic coma, 301 ; foul, in
scurvy, 314 ; fcBtid, in enlarged tonsils, 338.
Breathing (See Kespiration) ; mouth, 335.
Brick-maker's anaemia, 1032.
Bright's disease, acute, 741 ; diagnosis of, 743 ;
etiology of, 741 ; prognosis in, 744 ; symptoms
of, 742 ; treatment of, 744.
Bright's disease, chronic, 746 ; interstitial form
of, 749 ; causes of, 749 ; cardio- vascular
changes in, 753; hereditary influences in,
749 ; symptoms of, 752 ; treatment of, 755 ;
parenchymatous form of, 747.
Brisbane Hospital, statistics of Brand's
method at, 36.
" Broken-v/inded," 636.
Bromism, 956.
Bronchi, casts of, 502 ; diseases of, 490.
Bronchial catarrh (Bronchitis), 490.
Bronchial glands, tuberculosis of, 190, 193, 198,
207 ; enlargement in whooping cough, 86,
577 ; suppuration in, 577 ; perforation of into
oesophagus, 578.
Bronchieetivsis, 495 ; abscess of brain in, 497 ;
congenital, 495; cylindrical, 495; etiology
of, 495 ; rheumatoid affections in, 497 ; sac-
cular, 495; sputum in, 496; universalis, 495.
Bronchiolitis exudativa, 497.
Bronchitis, 490; acute, 490; etiology of, 490;
symptoms of, 490 ; treatment of, 491 ; capil-
lary, 536.
Bronchitis, chronic, 492 ; etiology of, 492 ;
symptoms of, 493 ; treatment of, 494.
Bronchitis, fibrinous, 501.
Bronchitis, in malaria, 146; in measles, 79;
in small-pox, 55 ; in typhoid fever, 23 ; pu-
trid, 494.
Bronchocele (see Goitre), 711.
Bronchophony, 520.
Broncho-pneumonia, acute, 536 ; chronic, 538;
acute tuberculous, 211.
Bronchorrhcea, 493 ; serous, 494.
Bronze -skin, in phthiriasis, 1048; in Addi-
son's disease, 709.
Brown induration of lung, 504.
Brown atrophy of heart, 643.
Brown-S<5quard's paralysis, 853.
Bruit, d'airain, 576; de cuir ncuf, 583; do
INDEX.
1055
dittble, 080; do pot f6l6 (sec Ckaokicd-pot
Sound), 227 ; do soufllo, r)94.
Bubo, parotid (soo also Pauotitis), 32S.
Bulbar paralysis, 860; acute, 860; chronic,
861 ; in progressive muscular atrophy, 860.
Bulimia, 300.
Butyric acid, test for, in gastric juice, 346.
Cachexia, in cancer of the stomach, 378, 383 ;
malarial, 153 ; saturnine, 1008; strumipriva,
715; syphilitic, 168.
Cajcitis, stercoral, 411.
Cajcum, perforation of, 406.
Caisson disease, 827.
Calcareous concretions, in phthisis, 216 ; in the
tonsils, 338.
Calcareous degeneration, of arteries, 663 ; of
heart, 643 ; of muscle fibres, 995.
Calcification, annular, of arteries, 663.
Calcification in tubercle, 195,
Calculi, biliary, 431 ; " coral," 765 ; pancreatic,
460 ; renal, 765 ; tonsillar, 338 ; urinary, forms
of, 765.
Calculous pyelitis, 758.
Calm, stage of, in yellow fever, 127.
Cancer, of bile-passages, 437, 453 ; of bowel,
415; of brain, 918; of gall-bladder, 453;
of kidney, 770 ; of liver, 451 ; of lung, 556 ;
of oesophagus, 342 ; of pancreas, 461 ; of perito-
naeum, miliary, 468 ; of pleura and lung, 556 ;
of stomach, 376.
Cancrum oris, 326.
California, southern, climate of, for tubercu-
losis, 251.
Canities, the result of neuralgia, 960.
Canned goods, poisoning by, 1014.
Capillary pulse, in aortic insufficiency, 606;
in neurasthenia, 980 ; in phthisis, 228.
Capsule, internal, lesions of, 897.
Caput Medusa?, 442, 470.
Caput quadratum, in rickets, 310.
Carboluria, 737.
Carbuncle in diabetes, 300.
Cardiac, compensation, rupture of, 634 ; disease
(see Disease of Heart).
Cardiac murmurs, hcBmic^ in chlorosis, 089 ; in
chorea, 930; in idiopathic anaemia, 693,
Cardiac murmurs, organic, in aortic insuffi-
ciency, 005; in aortic stenosis, 009; in con-
genital heart affections, 002; in mitral in-
competency, 013; in mitral stenosis, 010; in
tricuspid valve disease, 018.
Cardiac nerves, neuralgia of, 655.
fJardiac overstrain, 030.
Cardiac septa, anomalies of, 059.
Cardialgia (see Gahtkaloia).
Cardinal's case (hydrocephalus), 923.
Cardioccntesis, 048.
Cardio-respiratory murmur, 227.
Cardio-Hclerosis, 043.
Cardio-vascular changes in renal disease, 753.
Caries of spine, 851.
(Marinated abdomen, 203.
Carotid artery, ligature and compression of,
in cerebral haemorrhage, 882.
Carphologia, 25.
Carpo-pedal spasm, 906.
Carreau, 239.
Caseation, 195.
Casts, blood, of bronchial tubes in haemopty-
sis, 508; in fibrinous bronchitis, 502; of pel-
vis of kidney and ureter, 770.
Casts of urinary tubules, 744 ; epithelial, 742,
744 ; fatty, 748 ; granular, 748, 753.
Casts, tube, in acute Bright's disease, 742 ; in
chronic Bright's disease, 749, 758.
Catalepsy in hysteria, 975.
Cataract, diabetic, 302.
Catarrh, acute gastric, 348 ; autumnal, 477 ;
bronchial, 490; chronic gastric, 351; dry,
494 ; nasal, 475 ; simple chronic (nasal), 475 ;
sufi"ocative, 540.
Catarrhal inflammation, influence in tubercu-
losis, 193.
CataiThe sec, 494.
Catarrhus aestivus, 477.
Cats, diphtheria in, 100.
Cauda equina, lesions of, 854.
Cavernous breathing, 227.
Cavities, pulmonary, physical signs of, 227 ;
quiescent, 217.
Cellulitis of the neck, 332.
Centhocampa, 1050.
Centrum ovale, lesions of, 897.
Cephalalgia (see Headache).
Cephalic tetanus, 164.
Cephalodynia, 282.
Cercomonas intestinalis, 132.
Cerebellar, ataxia, 921 ; vertigo, 921.
Cerebellum, tumors of, 921.
Cerebral arteries, aneurism of, 883 ; arterio-
sclerosis of, 884 ; endarteritis of, 884 ; syphi-
litic endarteritis of, 884.
Cerebral haemorrhage, 870 ; aneurisms, miliary,
in, 871 ; convulsions in, 877 ; diagnosis of,
870; etiology of, 870; forms of, 871 ; morbid
anatomy of, 871 ; prognosis in, 877 ; symp-
toms of, 872 ; treatment of, 882.
Cerebral localization, 889.
" Cerebral pneumonia," 522.
" Cerebral rheumatism," 274.
Cerebral sinuses, thrombosis of, 885; softening,
878.
Cerebritis (see Encephalitis), 903.
Cerebro-spinal meningitis, epidemic, 92 ; anom-
alous forms of, 90 ; complications of, 96 ;
malignant form, 94.
Cerebro-spinal motor segment, lesions of, 894.
1056
INDPLX.
Cervical pachymeningitis, 821.
Cervico-brachiiil neuralgia, 960.
Cervico-oceipital neuralgia, 900.
C't'stodes, disease due to, 1036.
Chalicosis, 553.
Chancre, 166.
Charbon, 156.
('hdfcofs crystals, 390, 697 ; joints, 844.
Chattering teeth, 796.
Cheek, gangrene of, 326.
Cheese, poisoning by, 1014.
Cheesy pneumonia, 197.
Chest expansion, diminution of, in Graves's
disease, 714.
Cheyne-Stokes breathing, in apoplexy, 873 ; in
fatty heart, 644 ; in sunstroke, 1018 ; in tuber-
culous meningitis, 199; in uraemia, 739.
Chiasma and tract, atiections of, 787.
Chicken-breast, 310.
Chicken-pox, 65.
Child-crowing, 486.
Children, constipation in, 421 ; diabetes in, 300
tuberculous broncho - pneumonia in, 212
pneumonia in, 525 ; typhoid fever in, 29
tuberculosis of mesenteric glands in, 208
mortality from small-pox in, 56 ; rheumatism
in, 270.
Chills (see Rigors).
Chloasma phthisicorum, 230.
Chloro-antcmia in phthisis, 228.
Chlorosis, 686 ; and ancemia, sinus thrombosis
in, 885 ; diagnosis of, 689 ; dilatation of stom-
ach in, 688 ; Egyptian, 1032 ; etiology of,
686 ; fever in, 689 ; heart symptoms in, 689 ;
menstrual disturbance in, 689 ; morbid anat-
omy of, 687 ; symptoms of, 687 ; thrombosis
in, 689.
Choked disk, 786.
Choliemia, 425.
Cholangitis, catarrhal, 434; suppurative, 435.
Cholecystectomy, indications for, 439.
Cholecystitis, suppurative, 434; phlegmonous,
434.
Cholecystotomy. 439.
Cholera, asiatica, 118; bacillus of, 119; in-
fantum, 393 ; nostras, 123 ; sicca, 122 ; typhoid,
122.
Cholerine, 122.
ChoUilithiaais, 431.
('holestertemia, 425.
Cholesterine in biliary calculi, 432.
Clioluria, 737.
Chorea, acute, 929 ; etiology of, 929 ; heart
symptoms of, 936 ; infectious origin of, 933 ;
in pregnancy, 931 ; paralysis in, 935; rheu-
matism and, 930; seasonal relations of, 930.
Chorea, canine, 931, 945 ; chronic, 944.
Cliorea, habit or spasm, 942.
Chorea, Iluntinf/don'^s or liereditary, 944.
Chorea insaniens, 935 ; major, 942 ; pandemic,
942 ; prehemiplegic, 873 ; rhythmic or hys-
terical, 945 ; senile, 944 ; ISydenhani's^ 929.
Clioroid, tubercles in, 204.
Choroid plexuses, sclerosis of, 923.
Choroiditis in syphilis, 168.
Chyluria, non-parasitic, 730; parasitic, 1033.
Circumcision, inoculation of tuberculosis by,
189; in hsemophilia, 321.
Claw-hand (main en griffe), 859.
Climute, influence of; in asthma, 501; in chronic
Bright's disease, 755 ; in tuberculosis, 250.
Cicatrices fistuleuses, 217.
Ciliary muscle, paralysis of, 792.
Cimex lectularius, 1049.
Circulatory system, diseases of, 581.
Circumflex nerve, aflfections of, 815.
Cirrhosis, of kidney, 749 ; of liver, 440 ; of lung,
532; of pancreas, 460 ; ventriculi, 352.
Cladothrix, 261.
Clapotement, 366.
Clark\i, Alonzo^ sign, 411.
darkens, vesicular column, 842.
Claviceps purpurea, poisoning by, 1015.
Clavus hystericus, 971.
Cloisters, tuberculosis in, 190.
Clonus (see Ankle Clonus).
Clownism in hysteria, 969.
Cobalt miners, cancer of lung in, 556.
Coccidiuin oviforme, 1022.
Coccydynia, 961.
Cochin-China diarrhoea, 1036.
Coeliac affection in children, 394.
Coffee-ground vomit, 379.
Cog-wheel respiration, 226.
Coin-sound, 576.
Cold pack, method of giving, 75.
Colic, biliary, 432 ; in angio-neurotic oedema,
989; in purpura, 318; lead, 1009; renal, 767.
Colica Pictonum, 1007.
Colitis, mucous, 396 ; simple ulcerative, 397 ;
croupous, 524.
Collapse stage, in cholera, 121 ; in peritonitis,
464.
Collateral oedema of lung, 526.
Collective Investigation, Kcports of the British
Medical Association, 191, 270.
ColWs law, 166.
Colloid cancer, of lung, 556 ; of pcritonseum,
469 ; of stomach, 377.
Colon, cancer of, 415; dilatation of, 403.
Conuv, diabetic, 301 ; epileptic, 951 ; from
heat-stroke, 1018 ; in abscess of brain, 905 ; in
acute yellow atrophy, 427 ; in alcoholic poi-
soning, 1001 ; in apoplexy, 873, 877 ; in cere-
])ral sypliilis, 173; in general paresis, 916;
in multiple sclerosis, 914; in pernicious ma-
laria, 153 ; in thrombosis of cerebral sinuses,
885 ; in typhoid fever, 25 ; uramic, 739.
INDEX.
1057
Comatose form of Malaria, 153.
Coma-vigil, in typhoid fever, 25; in typhus
fever, 41.
Comma bacillus, 119.
Common bile-duct, obstruction of, 433.
Compensation in valve lesions, GOl ; periods
in, 634 ; rupture of, 634.
Composite portraiture in tuberculosis, 192.
Compression paraplegia, 851.
Concretions (see Calcareous).
Concussion of spinal cord, 983.
Confusional insanity, 25.
Congenital heart affections, 659.
Congenital syphilis, 169.
Congo-red test for free acid, 346.
Conjugate deviation; in brain tumor, 921; in
hemiplegia, 874 ; in meningitis, 204.
Consecutive nephritis, 758.
Constipation, 420; in adults, 420; in infants,
421 ; treatment of, 422.
Constitutional diseases, 270.
Consumption (see Tuberculosis), 208.
Contracted kidneys, 749.
Contracture, hysterical, 969 ; in hemiplegia,
875 ; of nurses, 965.
Contusion pneumonia, 512.
Conus arteriosus, stenosis of, 661.
Conus medullaris, lesions of, 854.
Convalescence, fever of, 13 ; from typhoid fever,
management of, 38.
Convulsions, epileptic, 951 ; hysterical, 954,
968 ; in acute yellow atrophy, 427 ; in alco-
holism, 1001 ; in aspiration of pleural effu-
sion, 571 ; in cerebral haemorrhage, 873 ; in
cerebral syphilis, 174, 954; in cerebral tu-
mors, 919 ; in chronic Bright's disease, 748.
Convulsions, infantile, 945 ; diagnosis of, 947 ;
etiology of, 945; relation to rickets, 311;
symptoms of, 946 ; treatment of, 947.
Convulsions, in general paralysis, 916 ; in he-
patic colic, 433 ; in infantile hemiplegia, 907 ;
in meningitis, 866; in sun-stroke, 1018; in
unemia, 739 ; Jacksonian, 953,
Convulsive tic, 942, 943.
Co-ordination, disturbance of, in tabes, 843.
Co{)aiba eruption, 80.
(Jopper test for sugar, 299.
Coi)rtEmia, 687.
Coprolalia, 943.
Cor adiposum, 643.
Cor biloculare, 659.
Cor bovinurn, 604.
Cor villosum, 582.
Cornea, ulceration of, in small-pox, 56.
Coronary arteries, in angina pectoris, 656 ; ob-
literation of, 641.
Coq*ora quadrigcmina, tumors in, 920.
Cor[)ulence, 1019.
(Jorriga7i?8 disease, 602.
Cnrr'ujaii'ii pulse, 606.
Coryza, acute, 474; foetida, 476; from the io-
dides, 183.
Costiveness, 420
Cougli, barking, of puberty, 972 ; hysterical,
97ti; in acute bronchitis, 491; in chronic
bronchitis, 493 ; in i)ertussis, 85 ; in phthisis,
220 ; during aspiration of pleui'al effusion,
570 ; in pneumonia, 519 ; paroxysmal, in
bronchiectasis, 496; paroxysmal, in fibroid
phthisis, 232 ; stomach, 354.
Coup de soleil, 1017.
Cow-pox, 60, 68.
Cracked-pot sound, 227.
Cramps, in cholera, 121 ; in gout, 292 ; in chronic
Bright's disease, 754.
Cranio-sclcrosis, 310.
Cranio-tabes, relation to congenital syphilis,
310 ; in rickets, 310.
Creophila, 1050.
Crescents in blood in malaria, 143.
Cretinism, foetal, 308; sporadic, 714.
Cretinoid change, 714.
Crises, gastro-intestinal ; in angio-neurotic
oedema, 989 ; in locomotor ataxia, 374, 844 ;
in purpura, 318.
Crisis, in pneumonia, 517 ; in typhus fever, 42.
Croup, 482 ; relation to diphtheria, 482 ; spas-
modic, 487.
Croupous pneumonia, 511.
Crura cerebri, lesions of, 897.
Crutch paralysis, 815.
CruveiUder's palsy, 857.
Cry, hydrocephalic, 202; hysterical, 972; in
congenital syphilis, 170.
Crystals, LeyderCs^ 500, 503.
Curdling ferment, test for, 347.
Curschmanii's spirals, 500, 503.
Cyanosis, in acute tuberculosis, 200 ; in congen-
ital heart-disease, 661 ; in emphysema, 647.
Cycloplcgia, 792,
Cynanche maligna, 99.
Cystic disease, of kidney, 772 ; of liver, 773.
Cystic duct, obstruction of, 433.
Cysticercus cellulos8e,1039 ; ocular, 1040 ; subcu-
taneous, 1040 ; symptoms of invasion of, 1040.
Cystine calculi, 734, 766.
Cystinuria, 734.
Cystitis, in locomotor ataxia, 844; in trans-
verse myelitis, 831 ; tuberculous, 244.
Cysts, in kidneys, 772; of brain, apoplectic,
872; porencephalic, 907; of brain, throm-
botic, 879 ; pancreatic, 460.
Dancing mania, 942.
Dandy fever (dengue), 90.
Deaf-mutism after cerebro-spinal fever, 97.
Deafness, in cerebral tumor, 921 ; in cerebro-
spinal meningitis, 97; in hysteria, 972; in
1058
INDEX.
Meniere's disease, 803 ; in scarlet fever, 73 ;
in tabes dorsalis, 844; nervous, 802.
Death, modes of, in tuberculosis, 234; sudden,
in typhoid fever, 31 ; in pleural effusion, 5G3.
Debility, nervous (see Neurasthenia), 978.
Dehovt's forced feeding, 253.
Decubitus, acute, 874; (bed-sores) in trans-
verse myelitis, 830.
Defensive alkaloids, 1012.
Degeneration, reaction of, 780, 799.
Deglutition, difficult (see Dysphagia).
Deglutition pneumonia, 537.
Deglutatory murmurs, auscultation of, 345.
Delayed resolution in pneumonia, 527.
Delayed sensation in tabes, 843.
Delirium, acute, 924 ; acute, in lead-poison-
ing, 1010; cordis, 32, 649, 651; expansive,
916; in acute rheumatism, 274; in pneu-
monia, 521 ; in typhoid fever, 25 ; in typhus
fever, 41 ; tremens, 1003.
Deltoid, paralysis of, 815.
Delasional insanity after fevers, 25, 55, 522.
Delusions of grandeur, 916.
Dementia paralytica, 914; alcohol as a factor in,
1002.
Demodex folliculorum, 1047.
Dengue, 90.
Dentition, in congenital syphilis, 171 ; in mer-
curial stomatitis, 327 ; in rickets, 310.
Dermatitis, exfoliative form, 73.
Dermatobia, 1050.
Desiccation in small-pox, 52.
Desquamation, in measles, 78 ; in rubella, 81 ;
in scarlet fever, 70 ; in small-pox, 52 ; in
typhoid fever, 15.
Deviation, secondary, 793.
Devonshire colic, 1007.
Dextrocardia, 659.
Diabetes insipidus, 305 ; heredity in, 305 ; in
abdominal tumor, 300 ; in tuberculous peri-
tonitis, 300.
Diabetes mellitus, 295 ; acute form, 298
chronic form, 298 ; coma in, 301 ; diet in
303 ; dietetic form, 298 ; gangrene in, 300
hereditary influences in, 295 ; in obesity
295 ; in children, 300 ; lipogenic form, 298
neurotic form, 298 ; pancreas in, 296, 297
pancreatic form, 298 ; paraplegia in, 302
theories of, 296 ; treatment of, 302 ; urine in,
298.
Diabetes, phosphatic, 735.
Diabetic, centre in medulla, 295 ; cirrhosis,
297 ; phthisis, 297 ; tabes, 301.
Diacetic acid, 737.
Diagnosis, topical, in brain-diseases, 887.
Diaphragm, paralysis of, 814 ; degeneration of
muscle of, 814.
Diarrhoea, 388 ; acute dyspeptic, 392 ; alba,
394 ; bacteria in, 391 ; chronic, treatment of,
400 ; chylosa, 394 ; endemic, of hot coun-
tries, 1036 ; from anchylostomiasis, 1031 :
hill, 395 ; in children, treatment of, 400 ; in
cholera, 121 ; in dysentery, 131, 135, 136 ; in
hysteria, 973 ; in phthisis, 229 ; in typhoid
fever, 20 ; in uraemia, 740 ; nervous, 389 ; of
Cochin-China, 1036 ; tubular, 396.
Diathesis, gouty, 288, 291 ; lithaemie, 733 ; tu-
berculous or scrofulous, 192.
Diazo-reaction in typhoid fever, 26.
Dicrotism of pulse in typhoid fever, 10, 17.
Diet, in chronic dyspepsia, 355 ; in constipa-
tion, 422 ; in convalescence from typhoid
fever, 38 ; in diabetes, 303 ; in gout, 293 ; in
infantile diarrhoea, 401 ; in leprosy, 257 ; in
obesity, 1020 ; in scurvy, 316 ; in tuberculo-
sis, 253 ; in typhoid fever, 33.
Digestive system, diseases of, 323.
Dilatation, of bronchi, 495 ; of stomach, 364.
Diphtheria, 99; and croup, 104, 482; bacillus
of, 100 ; contagiousness of, 99 ; diagnosis of,
108 ; in animals, 100 ; laryngeal, 104 ; mor-
bid anatomy of, 102 ; nephritis in, 106 ; neu-
ritis in, 107 ; of nares, 104 ; pseudo-diph-
theritic processes, 101 ; symptoms of, 103 ;
systemic infection, 105 ; treatment of, 109.
Diphtheritic, colitis, 395 ; membrane, histology
of, 102 ; processes in pneumonia, 516 ; pro-
cesses in typhoid fever, 27.
Diplegia, facial, 798 ; in children, 909.
Diplococcus, in empyema, 564; in endocar-
ditis, 596 ; in epidemic cerebro-spinal menin-
gitis, 93 ; in influenza, 88 ; in peritonitis, 463.
Diplococcus pneumoni83, 463, 512.
Diplopia (see Double Vision), 794.
Dipsomania (see Chronic Alcoholism), 1001.
Discrete fonn of small-pox, 51.
Disinfection, method of, in diphtheria, 109:
in typhoid fever, 32.
Dissecting aneurism, 670.
Distoma hepaticum ; D. lanceolatum ; D. eras-
sum ; D. endemicum ; D. perniciosum, 1024.
Distoma Ringeri, 1025.
Distomiasis, 1024.
DittriclCs plugs, 494.
Diuresis, 305.
Diver's paralysis, 827.
Diverticula of oesophagus, 344.
Dochmius duodenalis, 1031.
Dorsodynia, 282.
I)otl)i6ncnterite, 1.
Double vision, 794 ; in ataxia, 842.
Draeontiasis, 1034.
Dracunoulus mcdinensis, 1034.
Drainage, and diphtheria, 99 ; and scarlet fever,
68 ; and tonsillitis, 332 ; and typhoid fever, 4.
Dreamy state in epilepsy, 950.
Drepanidium ranarum, 143.
Dropsy, cardiac, treatment of, 626 ; in anap-
INDEX.
1059
mia (oedema), 692 ; in acute Bright's disease,
742 ; in aortic insufficiency, G07 ; in aortic
stenosis, 001) ; in cancer of stoniacli, 381 ; in
chronic Bri^'ht's disease, 754; in mitral in-
sufficiency, 012; in mitral stenosis, 018; in
phthisis, 230 ; in scarlet fever, 72.
I)ru_i,'-raslies, 74, 310.
Drunkenness, diagnosis from apoplexy, 877,
1001.
I) lichen lie's paralysis, 800.
Dulness, movable, in pleural ettusion, 562; in
pneumothorax, 576.
Dumb ague, 155.
Duodenal ulcer, diagnosis of, from gastric, 374.
Duodenum, defect of, 415 ; ulcer of, 308.
Dura mater, diseases of, 820, 862; haematoma
of, 862.
Durande's mixture, 438.
Duroziez's murmur, 006.
Dust, diseases due to, 534, 553 ; tubercle bacilli
in, 187.
Dysacusis, 802.
Dysentery, 130 ; abscess of liver in, 133, 137 ;
acute catarrhal, 131 ; amoeba coll in, 132 ;
chronic, 136; diphtheritic, 134; treatment
of, 138 ; tropical or amoebic, 132.
Dyspepsia, acute, 348 ; chronic, 351 ; nervous,
360 ; treatment of, 355.
Dyspnoea, cardiac, treatment of, 626 ; from
aneurism, 675; hysterical, 972, 982; in acute
tuberculosis, 200 ; in bilateral paralysis of
abductors, 806 ; in cardiac dilatation, 638 ; in
chlorosis, 689 ; in croup, 483 ; in diabetic
coma, 301; in mitral insufficiency, 612; in
mitral stenosis, 617; in pneumonia, 517 ; in
phthisis, 222 ; in oedema of the glottis, 482 ;
in spasmodic laryngitis, 486 ; urjemic, 739.
Dysphagia, hysterical, 340, 973 ; in cancer of
the oesophagus, 343 ; in hydrophobia, 160 ;
in oesophagi smus, 341 ; in oesophagitis, 340;
in pericardial effusion, 585; in thoracic
aneurism, 676 ; in tuberculous laryngitis, 488.
Dystrophy, primary muscular, 996.
Ear, complications of scarlet fever, 73 ; affec-
tions of, in syphilis, 168, 171.
Ears, care of, in scarlet fever, 76.
EhdaiiiPs method in obesity, 1020.
Eburnation of cartilages, 285.
Echinococcus disease, 1041.
Echinococcus, endogenous, 1042; exogenous,
1042; fluid, 1042; multilocular, 1046.
Ecliinorhynchus gigas; E. moniliformis, 1036.
Echokinesis, 943.
Echolalia, 943.
E<',lairipHia, 945.
Ectopia cordis, 659.
EhrlicK'H reaction in typhoid fever, 26.
Elastic tissue in sputum, 221.
67
Electrical reactions, in facial palsy, 799 ; in idio-
pathic nmscular atroi)hy, 997 ; in Landrifn
paralysis, 836; in nmltiple neuritis, 780 ; in
periodical paralysis, 980 ; in polio-myelitis
anterior, 833 ; in Thornseti's disease, 999.
Electrolysis in aneurism, 679.
Elephantiasis, 1034.
Emaciation, in anorexia nervosa, 973 ; in gas-
trie cancer, 378 ; in oesophageal cancer, 343 ;
in phthisis, 225.
Embolism, and aneurism, 671 ; in chorea, 933 ;
in typhoid fever, 19 ; of cerebral arteries, 878 ;
of cerebral arteries, diagnosis of, 880.
Embryocardia, 651.
Emphysema, 544 ; atrophic, 549 ; compensa-
tory, 544 ; hypertrophic, 545 ; hypertrophic,
cyanosis in, 547 ; hypertrophic, hereditary
character of, 545 ; interstitial, 544.
Emphysema, subcutaneous, after tracheotomy,
580 ; in gastric ulcer, 309 ; in phthisis, 230.
Emprosthotonos in tetanus, 104.
Empyema, bacteriology of, 504; necessitatis,
505, 077 ; perforation of lung in, 505 ; ter-
minations of, 565 ; treatment of, 570.
Encephalitis, meningo-, chronic diffuse, 914 ;
meningo-, foetal, 909 ; polio-, of Strumjoell^
907 ; suppurative, 903.
Encephalopathy, lead, 1010 ; syphilitic, 173.
Enohondroma of lung, 556.
Endocarditis, acute, 592 ; chronic, 599 ; diph-
theritic, 595; etiology of, 595; in chorea,
595, 932 ; infectious, 595 ; in the foetus, 001,
001 ; in gonorrhoea, 595 ; in pneumonia, 595 ;
in puerperal fever, 595 ; in rheumatism, 273,
595 ; in septici^mia, 595 ; in tuberculosis,
218, 594 ; malignant, 594 ; meningitis in,
595; micro-organisms in, 590; mural, 596;
recurring, 594 ; sclerotic, 001; simple or verru-
cose, 592 ; syphilitic, 178 ; ulcerative, 595.
Endophlebitis, 008.
Enteric fever (see Typhoid Fever), 1.
Enteritis, catarrhal, 388 ; croupous, 395 ; diph-
theritic, 395 ; in children, 391 ; phlegmonous,
396 ; membranous or tubular, 396 ; ulcerative,
397.
Entero-colitis, acute, 394, 465.
Enteroelysis, 124.
Enteroliths, 406, 416 ; as a cause of appendici-
tis, 406 ; in sacculi of colon, 421.
Enteroptosis, 718, 719, 980.
Entozoa (see Animal Parasites), 1022.
Environment, in tuberculosis, 250 ; experiment,
of Trudeau, 250.
Eosinophilcs in leukaemia, 699.
Ependymitis, purulent, 865, 924; granular, in
chronic alcoholism, 915.
Ephemeral fever, 264.
Epididymitis (see Orchitis), 179, 245.
Epilepsia, larvata, 953 ; nutans, 812.
1060
INDEX.
Epilepsy, 948 ; and syphilis, 949, 954 ; diaijno-
sis of, 953; etiology of, 948; heredity in,
949 ; in chronic ergotism, 1015 ; in general
paresis, 916; in lead-poisoning, 1010; in
Kaynau(rs disease, 988 ; in sunstroke, 1018 ;
Jacksonian^ 895, 953 ; masked, 953 ; phe-
nomena of, 812; post-epileptic symptoms of,
952; procursive, 951; rellex, 950; rotatory,
951 ; spinal, 838 ; surgical treatment of, 95G ;
treatment of, 955.
Epileptic fits, stages of, 951.
Epistaxis, 478 ; in haemophilia, 321 ; in scurvy,
314 ; in typhoid fever, 23 ; " renal," 723 ; vi-
carious, 479.
Epithelioid cells in tubercle, 195.
Ergotism, 1015; convulsive, 1015; gangrenous,
1015.
Erichseri's disease (railway spine), 981.
Erosion of teeth, 327.
Erroneous projection from strabismus, 794.
Eructations, 353.
Eruptions (see Rashes).
Erysipelas, 110 ; abscess in, 113 ; after vaccina-
tion, 61 ; complications of, 113 ; diagnosis of,
113; facial, 112; Fehleisen's^ streptococcus
of, 111 ; in typhoid fever, 27 ; migrans, 113 ;
puerperal, 111.
Erythema, exudativum,.3l7 ; in pellagra, 1016;
in typhoid fever, 15.
Erythrodextrin, test for, in gastric juice, 347.
Erythromelalgia, 962.
Exchar, ploughing, in hemiplegia, 874.
Eustrongulus gigas, 1036.
Exaltation of ideas in general paresis, 916.
Exanthematic typhus, 39.
Exfoliative dermatitis, 73.
Exophthalmic goitre, 712; acute form, 712;
diminution of electrical resistance in, 714;
pigmentation in, 713, tremor in, 713, urti-
caria in, 714.
Experts, medical, function of, in railway cases,
984.
Eye, motor nerves of, paralysis of, 793.
Eye-strain in migraine, 957.
Eyes, conjugate deviation of, in brain tumor,
921 ; in hemiplegia, 874 ; in meningitis, 204.
Facial, asymmetry, 810, 990 ; diplegia, 798 ;
hemiatrophy, 990 ; nerve, paralysis of, 797 ;
paralysis from cold, 798 ; paralysis from
lesion of trunk of nerve, 798 ; paralysis
from lesion of cortex, 797 , paralysis, symp-
toms of, 798.
Facial spasm, 800.
Facies, Hippocratic^ 464 ; leontina, in lepro-
sy, 258; in mouth -breathers, 337; Parkin-
sonian^ 928; syphilitic, 171.
Fsccal, accumulation, 416, 421 ; concretions, 406,
421 ; vomiting, 419.
Fjeces, bacteria in, 391 ; in jaundice, 424.
Falkenstein Sanitarium, 252.
Fallopian tubes, tuberculosis of, 245.
Famine fever (see Kelapsixg Fever), 43.
Farcy, acute, 260 ; chronic, 260.
Farcy-buds, 260.
Farre's tubercles, 452.
Fat embolism in diabetes, 301.
Fat necrosis, 459 ; of pancreas, in diabetes, 298.
Fatty degeneration, in anaemia, 691 ; of heart,
642 ; of kidneys, 747 ; of liver, 455.
Fatty stools, 461.
Febricula, 264.
Febris, carnis, 39 ; complicata, 267 ; recurrens,
43.
Feliling'^s test for sugar, 299.
Fermentation, fever, 114 ; test for sugar, 299.
Fever, in cholera, 121 ; gastric, 348 ; hysterical,
975 ; pernicious malarial, 153 ; in pneumonia,
517; in acute pnemnonic phthisis, 210, 211;
in acute miliary tuberculosis, 199 ; in primary
multiple neuritis, 777 ; in meningitic tuber-
culosis, 20*2 ; in pulmonary tuberculosis, 222 ;
in pyaemia, 117; in pylephlebitis, suppura-
tive, 450; in intermittent fever, 150; in re-
lapsing fever, 45 ; in remittent fever, 151 ; in
scarlet fever, 70 ; in septicaemia, 114 ; in
small-pox, 50; in sun-stroke, 1018; in appen-
dicitis, 410; in secondary syphilis, 167; in
typhoid fever, 13 ; in yellow fever, 127 ; lung,
511; Malta, 266; Mediterranean, 266; Nea-
politan, 266 ; ship, 39 ; splenic, 156 ; spotted,
39; typho-malarial, 152; yellow, 127.
Fever, intermittent, in abscess of liver, 448 ;
in ague, 150; in chronic obstruction of bile-
passages, 435; in gastric cancer, 381 ; in
Iloihjkiii's disease, 707 ; in pyaemia, 117 ; in
pyelitis, 760 ; in secondary syphilis, 167 ; in
tuberculosis, 219, 223.
Fibrillation, 859.
Fibrinous, bronchitis, 501 ; pneumonia, 511.
Fibro-caseous change in tubercles, 196.
Fibroid disease of heart, 641.
Fievre, inliammatoire, 1019 ; typholde k forme
r^nale, 26.
Fifth nerve, paralysis of, 795 ; gustatory bninch,
796 ; symptoms of, 796 ; trophic changes in
paralysis of, 796.
Filaria, Bancrqfti^ 1032; medinensis, 1034;
sanguinis hominis, 1032.
Filaria loa; F. lentis; F. labialis; F. hominis
oris ; F. bronchialis ; F. imitis, 1035.
Filariasis, 1032.
First sound of heart, obliteration of, in typhoid
fever, 17.
Fish, poisoning by, 1014.
Fii<h.er''s brain murmur, 310.
Fistula in ano in phthisis, 233, 241.
Flagellated organisms in blood in malaria, 143.
INDEX.
1061
Flatulence, in hysteria, 973; in nervous dys-
pepsia, 303 ; treatment of, 358.
FlinVs murmur in lieart-disease, G05, 61 G.
Floating kidney, 717.
Florida fever, 1019.
Fluke, bronchial, 1025.
Flukes, diseases caused by, 1024.
Foetal heart-rliythni, 651.
Foetus, endocarditis in, 660; syphilis in, 169;
tuberculosis in, 187, 188.
Folic Brightiquc, 738.
Follicular colitis, 394u
Food (see Diet).
Foot-drop, 777, 778.
Foreign bodies in intestines, 416.
Fourth nerve, 792 ; paralysis of, 793.
Fractures in rickets, 311.
Fremitus, vocal, 225, 520 ; hydatid, 1043.
Fresh-air treatment in tuberculosis, 250.
Friction, pericardial, 583 ; peritoneal, 468 ;
pleural, 227, 562 ; pleuro-pericardial, 227.
Friedreich'' 8 ataxia, 848.
FriedrelcJi's sign in adherent pericardium, 590.
Frontal convolutions, lesions of, 920.
Frontal sinuses, pentastomes in, 1047.
Fungi in pulmonary cavities, 222,
Gait, ataxic, 843; in pseudo-hypertrophic
muscular paralysis, 996 ; in spastic para-
plegia, 837 ; pseudo-tabetic, 845 ; steppage,
in peripheral neuritis, 779.
Gall-bladder, atrophy of, 434 ; calcification of,
434; dilatation of, 433; empyema of, 434;
forming abdominal tumor, 433 ; phlegmonous
inflammation of, 434.
Gall-stones, 431.
Gallop-rhythm, 651.
Galloping consumption, 209.
Galvano-puncture in aneurism, 679.
Game-birds, poisoning by, 1014.
Ganglia, basal, tumors of, 920.
Gangrene, in diabetes, 300 ; in ergotism, 1015 ;
in pneumonia, 527 ; in typhoid fever, 19 ; in
typhus, 42; local or symmetrical, 988; of
lung, 550 ; of mouth, 326.
GarrcMps thread test for uric acid, 289.
Gastralgia, 359.
Ga.strectiusis, 364.
Gastric, crises, 844 ; fever, 348.
Gastric juice, chemical examination of, 345;
hyperacidity of, 361, 370; subacidity of, 361.
Gastric ulcer, 368 ; clinical forms of, 372.
Gastritis, acute, 348; acute suppurative, 350;
chronic, 351 ; diphtheritic, 351 ; meinbranouH,
351 ; mycotic, 351 ; parasitic, 351 ; phlegirion-
ous, 350; polyposa, 352; sclerotic, 352; sim-
ple, 348; simple chronic, 352; toxic, 350.
Gastrodynia, 359.
(iastrorrbagia, 385.
Gastrotomy, 343.
Gastroxynsis, 361.
General paralysis of the insane (general pa-
resis), 914 ; diagnosis of, from syphilis, 173,
917; influence of syphilis in, 173.
Gcnito-urinary system, tuberculosis of, 243.
Gerlier'^s disease, 804.
German measles, 81.
Giant cells, 195.
Gigantoblasts, 693.
GilherVs syrup, 182.
Gilles de la Tourette''s disease, 943.
Gin-drinker's liver (see Cikuhosis of Liver),
440.
Girdle-feeling in transverse myelitis, 830.
Glanders, 259 ; acute, 260 ; chronic, 260 ; diag-
nosis from sraall-pox, 58.
Glioma of brain, 918.
Gliosis, 849.
Globulin in urine, 728.
Globus hystericus, 968.
Glomerulo-nephritis, 742.
Glosso-labio-laryngeal paralysis, 860.
Glosso-pharyngeal nerve, 805.
Glossy skin in arthritis deformans, 285.
Glottis, oedema of, 481 ; in Bright's disease,
481, 743 ; in small-pox, 55 ; in typhoid
fever, 9.
Gluteal nerve, 817.
Glycogen, formation of, 296.
Glycogenic function of liver, 296.
Glycosuria, 296, 737 ; gouty, 293.
GmeliriPs test, 424.
Goitre, 711; exophthalmic, 712; sudden death
in, 711 ; symptoms of, 711.
Gonorrhoeal rheumatism, 279 ; anatomical
changes in, 279 ; endocarditis in, 280.
Gout, 287 ; acute, 290 ; chronic, 291 ; Eh,stein?s
theory of, 288 ; etiology of, 287 ; hereditary
influence in, 287; influence of alcohol in,
287 ; influence of food in, 287 ; influence of
lead in, 288 ; irregular, 291 ; morbid anatomy
of, 288 ; nervous theory of, 288 ; retroccdent
or suppressed, 290 ; symptoms of, 290 ; treat-
ment of, 293.
Graefeh sign, 713.
Grain, poisoning by, 1015.
Grandeur, delusions of, 916.
Grand irial, 948.
Granular kidney, 749.
Gravel, renal, 765.
Graves's disease, 712.
Green-sickness (see Chlorosis), 686.
Green-stick fracture in ricketa, 311.
Gregarinidic, 1022.
(irinder's rot, 553.
Griftpc, la, 87.
(iuaiacum test for blood, 723.
Guinea-worm disease, 1034.
1062
INDEX.
Gummata, in acquired syphilis, 169; in con-
genital syphilis, 172; of brain and spinal
cord, 172; of heart, 178; of kidneys, 179; of
liver, 176; of lungs, 175; of rectum, 178; of
testis, 179; structure of, 167.
Gummatous periarteritis, 179.
Gums, black line on, in miners, 1009; blue
line on, in lead poisoning, 1008 ; in scurvy,
314 ; in stomatitis, 324 ; red line on, in pul-
monary tuberculosis, 228.
Gustatory paralysis, 796.
Habit spasm, 942 ; in mouth-breathers, 337.
Habitus, apoplectic, 870; phthisicus, 192.
Hffimatemesis, 385 ; causes of, 385 ; diagnosis
from ha3moptysis, 387 ; in enlarged spleen,
154; in scurvy, 314.
Ha^mato-chyluria, non - parasitic, 730; para-
sitic, 1033.
Haematogenous jaundice, 423.
Haematoma of dura, of brain, 862; of cord,
821
Hiematomyelia, 826.
Hsematorrhachis, 824.
Ilajmatozoa of malaria, 140, 142.
Hscmaturia, 722 ; as a sign of scurvy in chil-
dren, 315; endemic, of Egypt, 1024; in acute
nephritis, 742 ; in chronic phthisis, 230 ; in
psorospermiasis, 1023 ; in renal calculus,
768 ; in renal cancer, 770 ; in tuberculosis
of kidney, 244; malarial, 153.
Haemoglobin, reduction of, in chlorosis, 687.
Hajmoglobinuria, 723 ; epidemic, in infants,
171,724; in Raxjrhau(Vs disease, 988; parox-
ysmal, 724 ; toxic, 724.
Hsemolysis, in pernicious anaemia, 690 ; in toxic
haemoglobinuria, 725.
Ilaemo-pcricardium, 591.
Hapmothorax, 566.
Haemophilia, 320.
Haemoptysis, causes of, 506; hysterical, 972;
at onset of phthisis, 219; in acute broncho-
pneumonic phthisis, 213 ; in acute tubercu-
losis, 200 ; in aneurism, 507 ; in aortic insuf-
ficiency, 607; in arthritic subjects, 507; in
bronchiectasis, 497; in cirrhosis of lung,
535 ; in emphysema, 549 ; in miliary tuber-
culosis, 200 ; in mitral insufficiency, 612 ; in
mitral stenosis, 618 ; in pneumonia, 519 ; in
pulmonary gangrene, 551 ; in scurvy, 314 ;
symptoms of, 507 ; treatment of, 509 ; in ty-
phoid fever, 24 ; relation to tuberculosis,
507 ; parasitic, 1025 ; periodic, 507 ; vicari-
ous, 507.
Hemorrhage, cerebral, 870 ; in acute yellow
atrophy, 427 ; in ana^nia, 693 ; in cirrhosis
of the liver, 443 ; in contracted kidney, 753 ;
in haemophilia, 321; in hysteria, 972, 974;
in intussusception, 419 ; in leukaemia, 698 ;
in malaria, 153, 154 ; in nephrolithiasis, 768 :
in purpura haemorrhagica, 316 ; in scarlet
fever, 71 ; in scurvy, 314 ; in small-pox, 52 ;
in splenic enlargement, 154, 385, 702 ; into
spinal cord 826 ; in tuberculous pyelitis, 244 ;
into ventricles of brain, 872 ; in typhoid
fever, 21 ; in yellow fever, 127; pulmonary,
222.
Haemorrhagic diathesis, 320.
Hair tumors in stomach, 384.
Hair, the, in typhoid fever, 16.
Hallucinations in hysteria, 975.
Handwriting in general paresis, 916.
HarHson's groove in rickets, 310.
Harvest-bug, 1048.
Hay-asthma (hay-fever), 477.
Headache, from cerebral tumor, 919; in cere-
bral syphilis, 173 ; in mouth-breathers, 337 ;
in typhoid fever, 10, 11, 24 ; in uraemia, 739 ;
sick, 957.
Head-cheese, poisoning by, 1013.
Head-tetanus of Rose^ 164.
Heart, diseases of, 602 ; diseases of, OerteVa
treatment of, 646 ; amyloid degeneration of,
643 ; aneurism of, 646 ; athlete's, 602 ; brown
atrophy of, 643 ; calcareous degeneration of,
643; congenital affections of, 659 ; dilatation
of, 635 ; displacement in pleuritic effusion,
560 ; displacement in pneumothorax, 575 ;
fatty disease of, 642 ; fragmentation of fibres
of, 642 ; hydatids of, 648 ; hypertrophy of,
628; hypertrophy of, in Bright's disease,
753 ; in exophthalmic goitre, 713 ; irritable,
639, 649 ; palpitation of, 649 ; parenchyma-
tous degeneration of, 642 ; rupture of, 647 ;
sclerosis of, 641 ; valvular diseases of, 602,
Heart-f\iilure, in diphtheria, 107 ; treatment
of, in typhoid fever, 38.
Heart-muscle in fevers, 642.
Heart-valves, anomalies and lesions of, 660 ;
rupture of, 603.
Heat, exhaustion, 1017 ; stroke, 1017.
Ikherdeyi^s nodosities, 284.
Hebrews, prevalence of diabetes among, 295.
Hectic fever, 224.
Heel, painful, 961.
Heller's test, 727.
Helminthiasis (see Animal Parasites), 1022.
Ilemeralopia, 785 ; in scurvy, 315.
Hemiacliromatopia, 787.
Hemialbumose, 728.
Ilemiana^sthesia, in cerebral haemorrhage, 875 ;
in hysteria, 971 ; in lesions of internal capsule,
897 ; in unilateral cord lesions, 854.
Hemianopia, heteronymous, 787; homonymous,
787 ; in migraine, 957 ; lateral, 787 ; nasal,
788 ; significance of, 790 ; temporal, 787.
Hemicrania, 957.
Hemiplegia, 874 ; crossed, 875.
INDEX.
1063
Hemiplegia, infantile, 906 ; aphasia in, 908 ;
epilepsy in, 908 ; in hysteria, 9(59 ; mental
defects in, 908 ; post-hem iplegic movements
in, 908 ; spastica cerebralis, 908.
Ilemipl^gie Basque, 876.
Hepatic, abscess, 446 ; artery, enlargement of,
429; colic, 432; intermittent fever, 435; vein,
affections of, 429.
Hepatitis, diffuse syphilitic, 176 ; interstitial
(see Cirrhosis), 440 ; suppurative, 446.
Hepatization, of lung, 514 ; white, of foetus, 175.
Hepatogenous jaundice, 423.
Heredity, in Bright''s disease, 749 ; in diabe-
tes insipidus, 305 ; in hasmophilia, 320 ; in
idiopathic muscular atrophy, 996 ; in tuber-
culosis, 187 ; in tuberculosis, chart of, 188.
Herpes, in trifacial neuralgia, 960 ; in cere-
bro-spinal meningitis, 95 ; in febricula, 265 ;
in malaria, 150 ; in pneumonia, 521 ; zoster,
961.
Hiccough, hysterical, 972.
High-tension pulse, characters of, 753.
Hill diarrhoea, 395.
Hippocratic, facies, 464 ; fingers, 230 ; succus-
sion, 576.
Hippus, 958.
Hodgkin's disease, 704 ; intermittent fever in,
707 ; morbid anatomy of, 704 ; symptoms of,
705.
Horn-pox, 54.
Hot Springs, of Virginia, 279 ; of Arkansas,
279 ; of Banff, 279.
Huntingtort's chorea, 944.
Husband and wife, tuberculosis in, 191.
Hutchinson's teeth, 171.
Hyaline ca.sts in urine, 742, 748, 753.
Hybrid mea-sles, 81.
Hydatid disease (see Ecmxococcus), 1041 ;
prevalence of, in America, 1043.
Hydatid thrill or fremitus, 1043.
Hydrarthrosis, chronic, 280.
" Hydrocephaloid condition," 393, 869.
Hydrocephalus, acquired, 923 ; acute, 201 ;
chronic, 922; chronic, after cereljro-spinal
meningitis, 97 ; congenital, 922 ; spurious,
393.
Hydrochloric acid, tests for, in gastric juice, 346.
Hydromyelus, 849.
Hydronephrosis, 762; congenital, 762; inter-
mittent, 763.
Jfydropericardium, 591.
JIydroi)eritonaium, 469.
Hydrophobia, 159.
Hydrops vesica felleac, 433.
Ilydrothorax, 574.
llyjKiracuHis, 802.
HyperfEHthesia, in ataxia, 843 ; in hysteria, 971 ;
in rickets, 309 ; in uuikteral cord lesions, 854.
HyperoHinia, 783.
Hyperpyrexia, hysterical, 976 ; in rheumatic
fever, 273 ; in scarlet fever, 71 ; in sun-stroke,
1018; in tetanus, 164.
Hypnotism in hysteria, 978.
IIyi)ochondriasis and ncura.sthenia, 978.
Hypodermic syringe in diagnosis of pleural
effusion, 568.
Hypoglossal nerve, diseases of, 812 ; paraly-
sis of, 812 ; spasm of, 813.
Hypophysis, tumor of, 992.
Hypoplasia of aorta, 687.
Hypostatic congestion, in typhoid fever, 24;
of lungs, 505.
Hysteria, 967 ; contractures and spasms in,
969 ; convulsive forms of, 968; cries in, 972;
diagnosis of, 976 ; disorders of sensation in,
971 ; etiology of, 967 ; forms of fever in, 975 ;
htemoptysis in, 972 ; insanity in, 975 ; joint
affections in, 974 ; mental symptoms of, 974 ;
metabolism in, 975 ; metallotherapy in, 971 ;
non-convulsive forms of, 969 ; paralysis in,
969 ; special senses in, 972 ; stigmata in, 317,
974 ; traumatic, 981 ; treatment of, 976 ; vis-
ceral manifestations of, 972.
Hysterical angina pectoris, 657.
Hystero-epilepsy, 953, 968.
Hysterogenic points, 971.
Ice-cream, poisoning by, 1014.
Ice, typhoid bacillus in, 4.
Ichthysmus, 1014 ; paralyticus, 1015.
Icterus (see Jaundice), 423 ; acute febrile,
265 ; gravis, 426 ; neonatorum, 425.
Idiopathic anaemia of Addison, 689.
Idiocy in infantile hemiplegia, 908.
Ileo-ca2cal region, in typhoid fever, 22 ; in ap-
pendicitis, 410 ; in primary tuberculosis of
bowel, 241.
Ileus (see SxRANGrLATioN of Bowel), 413.
Imbecility in infantile hemiplegia, 908.
Imitation in chorea, 932.
Impotence, in diabetes, 302 ; in locomotor atax-
ia, 844.
Incarceration of bowel, '413.
Incoordination, of arms, 843 ; of legs, 843.
Indians, American, chorea in, 930 ; consump-
tion in, 185 ; small-pox among, 47.
Indicanuria, 735.
Infantile, convulsions, 945 ; paralysis, 831.
Infantilism, 171.
Infarcts, hoemorrhagic, in typhoid fever, 19;
pya'mic, 116.
Inflation of bowel for intussusception, 420.
Influenza, 87 ; diagnosis of, 89 ; etiology of,
88 ; symptoms of, 88 ; treatment of, 89 ; com-
plications of, 88.
Inhalation-pneumonia (see Aspiration Pneu-
monia), 537.
Inhibition centre of Kronecker^ 649.
1064
INDEX.
Injection, intravenous, of milk, 124 ; intra-
venous, of salines in diabetes, 305 ; subcu-
taneous, of salines in cholera, 124.
Inoculation, aijainst small-pox, 40, 54 ; pro-
tective, in cholera, 123 ; protective, in hydro-
phobia, 161 ; protective, in pneumonia, 513;
protective, in yellow fever, 129 ; tuberculosis
transmitted by, 188.
Insanity, post-febrile, 25 ; in small-pox, 55,
Insanity, relation of drink to, 1002 ; relations
of chronic phthisis to, 229 ; relation of heart-
disease to, 607.
Insects, parasitic, 1048.
Insolation, 1017.
Insular sclerosis, 913.
Intention tremor (see Volitional Tremor).
Intermittent fever, 147 ; forms of (see Fever).
Intermittent hepatic fever, 435.
Internal capsule, lesions of, 897.
Internal carotid artery, blocking of, 881.
Intestinal casts, 396.
Intestinal coils, tumor formed by, 238.
Intestines, diseases of, 388 ; actinomycosis of,
262 ; dilatation of, 403.
Intestines, haemorrhage from, in typhoid fever,
8, 21 ; in dysentery, 131, 135; in tuberculosis
of bowel, 240; in intussusception, 419; in
ulceration of, 397.
Intestines, infarction of, 404 ; intussusception of,
414, 419 ; invagination of, 414 ; miscellaneous
affections of, 403 ; new growths in, 415.
Intestines, obstruction of, 413, 465 ; acute, 416 ;
by enteroliths, 416 ; by foreign bodies, 416;
by gall-stones, 416.
Intestines, perforation of, in typhoid fever, 7.
Intestines, primary tuberculosis of, 240 ; stran-
gulation of, 413, 418 ; strictures and tmnors of,
415 ; twists and knots in, 415 ; ulcers of, 397.
Intoxications, 1001.
Intussusception, 414, 419.
Invagination, 414; post-mortem, 414.
Inverse type of temperature, in tuberculous
meningitis, 199; in typhoid fever, 13.
Iodide eruptions, 183.
Iridoplegia, 792; accommodative, 792; reflex,
792.
Iritis, syphilitic, 168, 171.
Itch, 1047.
Itch insects, 1047.
Itching, of feet in gout, 292; of eyeballs in
gout, 292; of skin in Bright's disease, 754.
Ixodes ricinus ; I. americanus, 1048.
Jaoksonian epilepsy, 895, 953.
Japan, Beri-beri in, 780; endemic fluke dis-
ease in, 1024.
Jaundice, black, 424; catan-hal, 430; choluria
in, 424 ; from cirrhosis of liver, 443, 444 ; epi-
demic form of, 430 ; febrile, 265 ; from acute
yellow atrophy, 426 ; from cancer of liver, 454 ;
from gall-stones, 433, 435; haematogenous,
423 ; hepatogenous, 423 ; in pneumonia, 524 ;
in WeiPs disease, 265; malignant, 426; of
the new-born, 425 ; xanthelasma in, 424 ; in
yellow fever, 127.
Johns Hopkins Hospital, statistics of tubercu-
losis at, 185, 188.
Joints (see Arthritis).
Jumpers, 943.
"June cold," 477.
Keloid of Addison, 993.
Keratitis, in small-pox, 56 ; interstitial, of in-
herited syphilis, 171.
Keratosis follicularis, 1023.
Kidney, diseases of, 717 ; amyloid or larda-
ceous disease of, 757 ; anomalies in form and
position of, 717 ; cancer of, 770 ; cardiac,
722 ; circulatory disturbance in, 721 ; cirr-
hosis of, 749 ; congenital cystic, 772 ; con-
gestion of, 721 ; contracted, 749 ; cyanotic in-
duration of, 722 ; cystic disea.se of, 772 ; echi-
nococcus of, 1045; fused, 717; gouty, 749;
granular, 749 ; horseshoe, 717 ; large white,
746, 747 ; movable, 717.
Kidney, removal of, for cancer, 771 ; for mova-
ble kidney, 720.
Kidney, rhabdo-myoma of, 770; sarcoma of,
770; scrofulous, 244; small white kidney,
747 ; surgical kidney, 759 ; syphilis of, 179 ;
tuberculosis of, 243 ; tumors of, 770 ; un.sym -
metrical, 717.
Knee-jerk, loss of, in ataxia, 842 ; in diphtheria,
108.
Koch treatment of tuberculosis, 252.
Lactic acid, test for, in gastric juice, 346.
Landry's paralysis, 835.
Lardaccous degeneration (see Amyloid).
Larva of flies, diseases caused by (myiasis),
1050.
Laryngeal crises, 844.
Laryngismus stridulus, 486.
Laryngitis, acute catarrhal, 480; chronic, 481 ;
membranous, 482 ; oedematous, 481 ; spas-
modic, 486 ; syphilitic, 489 ; tuberculous, 487.
Larynx, diseases of, 480, 806 ; adductor paral-
ysis of, 807 ; antcsthesia of, 808 ; hypenvsthe-
sia of, 808 ; paralysis of abductors of, 807 ;
spasm of the muscles of, 808; unilateral ab-
ductor paralysis of, 807.
Lata, 943.
Lateral sclerosis— primar}-, 837 ; amyotrophic,
857.
Lateritioua deposit, 732.
Lathyrism, 1016.
Lavage, 357 ; in dilatation of stomach, 367 ; in
gastric ulcer, 375.
INDEX.
10G5
Lead, colic, 1009 ; in the urine, 1008.
Lead-palsy, 1009 ; localized forms of, 1009.
Lead-pipe contraction, 838.
Lead-poisoning, 1007; acute, 1008; arterio-
sclerosis in, 1010 ; cerebral pyniptoius in,
1010; chronic, 1008; gouty deposits in, 1010;
treatment of, 1010.
Lead-workers, prevalence of gout in, 288.
Leichen-tubercle, 189.
Lepra alba, 258.
Lepra mutilans, 258.
Leprosy, 256 ; anaesthetic, 258 ; bacillus lepra
in, 258 ; contagiousness of, 257 ; diagnosis
of, 259 ; etiology of, 256 ; macular form of,
258 ; morbid anatomy of, 258 ; treatment of,
259 ; tubercular, 258.
Leptomeningitis, acute, 863 ; chronic, 867 ; in
Bright's disease, 86i; infantum, 864, 865; in
pneumonia, 864.
Leptothrix in mouth, 263.
Leptus autumnalis, 1048.
Leucin, 427.
Leucocytes, varieties of, 699.
Leucoderma, 713.
Leucomaines, 1012.
Leucomata, 168.
Leuka'niia, 696 ; acute lymphatic, 700 ; blood
in, 699 ; congenital, 697 ; detinition of, 696 ;
diagnosis of, 702 ; etiology of, 696 ; heredi-
ty in, 697 ; in animals, 697 ; in pregnancy,
697 ; morbid anatomy of, 697 ; myelogenous,
698 ; prognosis of, 703 ; symptoms of, 698 ;
treatment of, 703.
LeyderCs crystals, 500, 503.
Lichtheim's schema, 899.
Lienteric diarrhoea, 390.
Life assurance, and albuminuria, 729 ; and
syphilis, 183.
Lightning pains in ataxia, 842.
Lipaciduria, 736.
Lip?emia, 297, 301.
Lipuria, 736.
Lips, tuberculosis of, 239.
Lisaauer's tract, 842.
Lithffiinia, 730, 733.
Lithaemic state, 291.
Lithiasis, 733.
Lithic-acid diathesis, 730.
Lithuria, 730.
Liver, abscess of, 446 ; actinomycosis of, 262;
acute yellow atrophy of, 426 ; amyloid, 456 ;
anamia of, 427 ; angioma of, 453 ; cardiac, 428.
Liver, cirrhosis of, 440 ; ascites in, 443; atro-
phic, 441 ; fatty, 441 ; Glissonian^ 441 ; haem-
orrhage from stomach in, 443 ; hypertrophic,
441, 444 ; in acute tuberculosis, 242 ; in chil-
dren, 440; jaundice in, 443; t<^xic symp-
toms in, 443 ; with cancer, 452.
Liver, cystx of, 453; fatty, 455; gummata of,
176 ; hepatophlebotomy in congestion of, 429 ;
liydatids of, 1043 ; hyperaimia of, 427 ; infarc-
tion of, 429 ; melano-sarcoma of, 453 ; new
growths in, 451 : nutmeg, 428 ; i)a,ssive con-
gestion of, 428 ; periodical enlargement of,
428 ; primary cancer of, 452 ; psorospermiasis
of, 1022 ; pulsation of, 428 ; sarcoma of, 453 ;
secondary cancer of, 452 ; syphilis of, 176 ;
tuberculosis of, 242.
Liver dulness, obliteration of in perforative
peritonitis, 23.
Living skeletons, 859.
Lobar pneumonia, 511.
Lohstehi's cancer, 771.
Localization, cerebral, 889 ; spinal, 887.
Lock-jaw, 162.
Lock-spasm, 964.
Locomotor ataxia, 840 ; diagnosis of, 845 ; eti-
ology of, 841 ; hemiplegia in, 845 ; morbid
anatomy of, 841 ; paresis in, 845 ; prognosis
of, 846 ; relation of syphilis to, 841 ; reputed
cures of, 846 ; symptoms of, 842 ; treatment
of, 846.
Long thoracic nerve, afiections of, 815.
Lordosis, 859.
Loreta's operation, 367.
Louis' law, 193.
Ludwig's angina, 332.
Lues venerea, 165.
Lumbago, 281.
Lung, abscess of, 552 ; causes of, 552 ; embolic,
552 ; etiology of, 552 ; symptoms of, 552.
Lung, actinomycosis of, 262 ; albinism of, 546 ;
brown induration of, 504 ; cancer of, acute,
557 ; carniiication of, 538 ; cirrhosis of, 532.
Lung, diseases of, 503 ; stones, 216.
Lung fever, 511.
Lungs, congestion of, 503 ; active, 503 ; acute
hsemorrhagic, 504 ; hypostatic, 505 ; mechani-
cal, 504 ; passive, 504.
Lungs, echinococcus of, 1045.
Lungs, gangrene of, 550 ; abscess of brain in,
551 ; causes of, 550 ; etiology of, 550 ; mor-
bid anatomy of, 550 ; symptoms and course
of, 551 ; treatment of, 551 ; hemorrhagic In-
farction of, 508.
Lungs, new growths in, 556 ; in cobaltrminers^
556 ; pliysical signs of, 557 ; diagnosis of, 557..
Lungs, axlema of, 505 ; splenization of, 505,,
538 ; syphilis of, 174; tuberculosis of, 208.
Lupinosis, 1016.
Lymphadenitis, general tuberculous, 206 ; local
tuberculous, 206 ; suiiple, 577 ; suppurative,
577.
Lymphadenoma, general, 704.
T^ymph -scrotum, 1034.
Lymph, vaccine, 63.
Lymph vessels, dilatation of, 1034.
Lyssa, 159.
1066
INDEX.
Macular syphilulcs, 168.
Main en gritte, 851).
Maize, poisoning by (pellagra), 1016.
Malarial fever, 140 ; accidental and late lesions
of, 146 ; algid form of, lo3 ; comatose form
of, 153 ; continued and remittent form of,
151 ; description of the paroxysm in, 147 ;
diagnosis of, 154 ; etiology of, 140 ; geo-
graphical distribution of, 140 ; hemorrhagic
form of, 153 ; intermittent, 147 ; malarial
cachexia, 145, 153 ; meteorological conditions
influencing, 142; morbid anatomy of, 144;
pernicious, 144, 152 ; quartan, 151 ; quotidi-
an, 150 ; season in, 141 ; specific germ of,
142 ; telluric conditions influencing, 141 ;
tertian, 150 ; treatment of, 155.
Malignant, oedema, 157 ; pustule, 157.
Malta fever, 260.
Mammary glands, hypertrophy in tuberculosis,
230 ; in hysteria, 970.
Mammitis, chronic interstitial, in tuberculosis,
230.
Mania a potu, 1003.
Mania, Bell's, 924.
Marantic thrombi, 885.
Marine Hospital Service, statistics of malaria
in, 140.
Marriage, question of, in liocmophilia, 322 ; in
syphilis, 183 ; in tabes dorsalis, 847 ; in tu-
berculosis, 247.
Marrow of bones, in small-pox, 49 ; in leu-
ka}mia, 098 ; in pernicious anoemia, 691.
Masque des femmes enciente, 710.
Massachusetts General Hospital, regulations
regarding disinfection in typhoid fever at,
32 ; statistics of typhoid cases at, 29 ; typhus
fever at, 2.
Mastication, spasm of the muscles of, 790.
McBurney'''i tender point, 411.
Measles, 77 ; complications and scqueljB of, 79 ;
contagiousness of, 77 ; desquamation in, 78 ;
diagnosis of, 80 ; eruption in, 78 ; etiology
of, 77 ; German, 81 ; morbid anatomy of, 77 ;
period of incubation in, 77 ; prognosis of,
80 ; symptoms of, 77 ; treatment of, 80.
Measly meat, examination of, 1038.
Meat, poisoning by, 1013 ; tuberculous infec-
tion by, 191 ; inspection of, for trichinae,
1028.
McclceVs diverticulum, 413.
Median nerve, att"ections of, 816.
Mediastinum, affections of, 577 ; abscess of,
579 ; tumors of, 578 ; cancer of, 578 ; diagnosis
of, 579 ; pleural elfusion in, 579 ; sarcoma of,
578 ; ftymptoms of, 578.
Mediterranean fever, 266.
Medulla oblongata, tumors of, 921.
Megalocytes, 692.
Mcgafctrie, 364.
Melsena, in duodenal ulcer, 374; in typhoid
fever, 21 ; neonatorum, 386.
Melano-sarcoma of liver, 453.
Melanuria, 736.
Melasma suprarenale, 710.
Meniere's disease, 803.
Meningeal haemorrhage, 871 ; in birth palsies,
909.
Meninges, affections of, 820.
Meningitis, acute spinal, 822 ; in erysipelas,
111; in gout, 292; posterior, 924; tubercu-
lous, 201 (see also Leptomeningitis, 863).
Meningo-encephalitis, chronic diffuse, 914;
tuberculous, 202.
Mercurial tremor, 929.
Merycismus, 362.
Mesenteric artery, embolism of, 404.
Mesenteric glands, tuberculosis of, 208 ; tuber-
culous tumors of, 239 ; in typhoid fever, 8.
Mesentery, hiemorrhage into, 457.
Mesocolon, hicmorrhage into, 457.
Metallic, echo, 576 ; tinkling, 227, 576.
Metallotherapy, 971.
Metastasis in mumps, 83.
Metastatic abscesses, 116.
Meteorism in typhoid fever, treatment of, 37.
Micrococci, in chorea, 934 ; in dengue, 90 ; in
Malta fever, 267 ; in rheumatic fever, 271 ; in
vaccine virus, 60 ; in varicella, 65.
Microcytes, 692.
Middle cerebral artery, embolism and throm-
bosis of, 881.
Migraine, 957 ; treatment of, 958.
Miliary abscesses in typhoid fever, 8.
Miliary aneurism, 871.
Miliary fever, 268 ; epidemics of, 268.
Miliary tubercle, 195 ; tuberculosis, acute, 197 ;
tuberculosis, chronic, 215.
Milk, and scarlet fever, 67 ; and typhoid fever,
5 ; products, poisoning by, 1014 ; sickness,
266 ; tuberculous infection by, 191.
Mind-blindness, 900.
Mind-deafness, 900.
Miner's, anaemia or cachexia, 1032 ; lung, 553 ;
nystagmus, 792 ; sarcoma of lung, 556.
Miryachit, 943.
Mitchell, "Weir, treatment in hysteria, 977.
Mitral incompetency, 610; diagnosis of, 614;
etiology of, 610; morbid anatomy of, 610;
physical signs of, 613 ; symptoms of, 612.
Mitral stenosis, 614; chorea and, 614; etiology
of, 614 ; morbid anatomy of, 615 ; physical
signs of, 616; presystolic murmur in, 616;
rheumatism and, 614; symptoms of, 616.
Moist sounds, 226.
Molluscum contagiosum, psorosperms in, 1023.
Monoplegia, 895, 896 ; facial, 797 ; in hysteria,
969 ; in traumatic neuroses, 983.
Montaigne on renal colic, 767.
INDEX.
1067
Montreal General Hospital, autopsies in diph-
theria, 102 ; in typlioid fever, 5 ; deatli-rate
from typhoid fever at, 31. Statistics, of apex
lesions in 1,000 autopsies, 241) ; of dysentery,
130; of hemorrhagic small-pox, 52; of pneu-
monia, 527 ; of rheumatic fever, 270 ; of ty-
phoid fever, 2, 3.
Montreal small-pox epidemic ]885-'86, 56, 65.
Morbilli haemorrhagici, 79.
Morbus cacruleus, 602.
Morbus, coxae senilis, 284, 286 ; errorum, 1048 ;
maculosus, 318.
Morphia habit, 1005 ; treatment of, 1000.
Morphinism, 1005.
Morphiomania, 1005.
Morphoea, 993.
Mortality, in eerebro-spinal meningitis, 98 ; in
pneumonia, 527 ; in typhoid fever, 31 ; in
whooping-cough, 80 ; in yellow fever, 128.
Morvan's disease, 850.
Mosquitoes, relation of, to filaria disease, 1033.
Motor centres, 889.
Motor, nuclei, chronic degeneration of, 857 ;
system, lesions of, 892.
Mountain, anaemia, 1032 ; fever, 208.
Mouth-breathing, 335.
Mouth, diseases of, 323 ; putrid sore, 324.
Movable kidney, 717 ; dilatation of stomach in,
719 ; symptoms of, 719 ; treatment of, 720.
Mucous colitis, 390.
Mucous patches, 108.
Muguet, 325.
" Mulben-y " calculi, 705.
Mumps. 82.
Munich Pathological Institute, statistics of au-
topsies in typhoid fever at, 5 ; of tuberculo-
sis in children at, 234.
Munich, reduction of typhoid mortality in, 32.
Murmur, in aneurism, 674 ; brain, 310 ; cardio-
respiratory, 227 ; in congenital heart-disease,
602 ; Flint's, 605 ; haemic, 089 ; in endocar-
ditis, 594 ; in lung cavity, 227 ; in subclavian
artery in phthisis, 227; in valvular disease,
605, 609, 613, 616, 619.
Musca domestica, 1050 ; M. vomitoria, 1050.
Muscle callus in sterno-mastoid in infants, 810.
Muscles, diseases of, 995 ; degeneration of, in
typhoid fever, 10.
Muscular atrophy, idiopathic, 996; facio-hu-
meral type, 997 ; from lesions of motor nu-
clei, 996 ; from neuritis, 996 ; hereditary form
of Leyden, 997 ; heredity in, 996 ; juvenile
type of Erb, 997 ; peroneal form, 997 ; pri-
mary atrophic form, 997 ; in hemiplegia, 876.
Muscular atrophy, progressive spinal, 857 ; eti-
ology of, 85H ; hereditary influence in, 858;
morbid anatomy of, 858 ; symptoms of, 859.
Muscular contractures, in hemiplegia, 975 ; in
hysteria, 970.
Muscular rheumatism, 281.
Museulo-spiral paralysis, 815.
Musical faculty, loss of, in aphasia, 901.
Musical murmurs, 609, 602.
Mussel poisoning, 1014.
Myalgia, 281.
Mycosis intestinalis, 158.
Myelin degeneration of alveolar cells, 491.
Myelitis, acute central, 829 ; acute diffuse, 828 ;
acute transverse, 830 ; compression, 851 ; in
measles, 80 ; of anterior horns, 831 ; reflexes
in, 830 ; transverse, of cervical region, 831.
Myelocytes, 700.
Myelogenous leukaemia, 098.
Myiasis, 1050 ; of nostrils and of ears, 1050 ;
vulnerum, 1050.
Myocarditis, 041 ; acute interstitial, 041 ; fibrous,
641 ; in rheumatism, 274 ; prognosis of, 645 ;
symptoms of, 643 ; syphilis in, 178 ; treat-
ment of, 645.
Myocardium, diseases of, 640 ; lesions of, due
to disease of coronary arteries, 640.
Myopathies, the primary, 990 ; diagnosis of, 998.
Myositis, 995 ; ossificans progressive, 995.
Myotonia congenita, 998.
Myotonic reaction of Erb, 999.
Mytilotoxine, 1015.
Myxoedema, 714 ; acute, 715 ; congenital form,
714 ; operative, 715.
Nails, in typhoid fever, 16 ; in phthisis, 230.
Nasal diphtheria, 104.
Naso-pharyngeal obstruction, 335.
Neapolitan fever, 266.
Necrosis, acute, of bone, 275; in tubercle, 195 ;
in typhoid fever, 27.
Nematodes, diseases caused by, 1025.
Isematoid worms in the common duct, 437.
Nephralgia, 962.
Nephritis, 741 ; acute, 741 : after diphtheria,
106 ; chronic, 746 ; chronic hieinorrhagie,
748.
Nephritis, chronic interstitial, 749 ; diagnosis of,
754 ; etiology of, 749 ; haemorrhages in, 754 ;
increased tension in, 753 ; morbid anatomy
of, 750 ; prognosis of, 755 ; relation of heart
hypertrophy to, 751 ; symptoms of, 752 ;
treatment of, 755; urine in, 752; vomiting
in, 754.
Nephritis, chronic parenchymatous, 747 ; con-
secutive, 758 ; in erysipelas, 113; in chronic
su[)puration, 747 ; in malaria, 147, 747 ; in
scarlet fever, 71.
Nephritis, lymphomatous, 27 ; 8upj)urative, 759.
Nephrolithiasis, 765 ; symptoms of, 766.
Nephro-phthisis (see Kidney, Tubekculosis
ok).
Nephroptosis, 717.
Nephrorrhaphy, 720.
1068
INDEX.
Nephrotomy, 762.
Nephro-typhus, 26.
" Nerve-storms," 95S.
Nerves, diseases of, 775 ; diseases of cranial,
782 ; diseases of spinal, 813.
Nervc-tibres, inflammation of, 775.
Nerves, lesions of, 815 ; anterior crural, 817 ;
circumflex, 515 ; external popliteal, 818 ;
gluteal, 817 ; internal popliteal, 818 : long
thoracic, 815 ; median, 81G ; niusculo-spiral,
815 ; obturator, 817 ; sciatic, 817 ; small sci-
atic, 817 ; ulnar, 816.
Nerve-root symptoms, 851.
Nervous diarrhoea, 973.
Nettle rash (see Urticaria).
Neuralgia, 959 ; causes of, 959 ; cervico-bra-
chial, 9G0 ; cervico-occipital, 813, 960 ; influ-
ence of malaria in, 959; intercostal, 961;
lumbar, 961 ; of nerves of feet, 961 ; phrenic,
961 ; plruitar, 962 ; reflex irritation in, 959 :
treatment of, 962 ; trifacial, 960 ; visceral,
962.
Neurasthenia, 978 ; etiology of, 978 ; symptoms
of, 979 ; traumatic, 981 ; treatment of, 985.
Neuritis, 775 ; fascians, 776 ; interstitial, 775 ;
lipomatous, 776 ; localized, 775, 776 ; paren-
chymatous, 776 ; multiple, 775, 777 ; alco-
holic, 778 ; arsenical, 779 ; diagnosis of, 780 ;
endemic, 780; in diphtheria, 107; in chronic
phthisis, 229; recurring, 778; saturnine, 779 ;
treatment of, 781 ; optic, 786.
Neuroglioma, 918.
Neuroma, plexiform, 782.
Neuromata, 781.
Neuroses, occupation, 963 ; traumatic, 981 ; di-
agnosis of, 984 ; etiology of, 981 ; prognosis
of, 984 ; symptoms of, 981.
Neutrophiles, 699.
Night-blindness, 785 ; in scurvy, 315,
Night-sweats in phthisis, 225 ; treatment of,
255.
Nipple, Paffefs disease of, 1023.
Nitric-acid tost for albumen, 727.
Nits, 1048.
Nodding spasm, 812.
Nodes, symmetrical, in congenital syphilis, 171.
Nodosities, I/ehefdeii\<i, 284.
Nodules, rheumatic, 275.
Noma, 326.
Normoblasts, 692.
Nose, bleeding from (see Epistaxis), 478.
Nose, disea.ses of, 474.
Nose-bleeding in typhoid fever, 10.
Nummular sputa in plithisis, 220.
Nurse's contracture of Trousseau, 965.
Nutmeg liver, 428.
Nyctalopia, 785; in scurvy, 315.
Nystagmus, 792; in 7v-iV^//'t'iWi'.<i ataxia, 849; in
insular sclerosis, 914; of miners, 792.
Obesity, 1019.
Obsession, 943.
Obstruction of bowels, 413 ; acute, 416 ; chronic,
417.
Obturator nerve, 817.
Occipital lobes, tumors of, 920.
Occupation neuroses, 963.
Ocular palsies, treatment of, 795.
Oculo-niotor paralysis, recurring, 791.
Odor, in small-pox, 59 ; in typhoid fever, 16.
(Edema, angio - neurotic, 989 ; collateral, in
lungs, 506 ; febrile purpuric, 318 ; of lungs,
505 ; malignant, 157 ; of brain in uraemia, 870.
CEdematous laryngitis, 481.
QEsophageal bruit, 341.
(Esophagismus, 340.
(Esophagitis, acute, 339 ; chronic, 340.
(Esophagus, diseases of, 339 ; cancer of, 342 ;
dilatations of, 344; diverticula of, 344; pa-
ralysis of, 341 ; post-mortem digestion of,
343 ; rupture of, 343 ; spasm of, 340 ; strict-
ure of, 341 ; syphilis of, 178 ; tuberculosis
of, 240.
OertePs method in obesity, 645, 1020.
Oklium albicans, 325.
Olfactory nerve, 782.
Omentum, tuberculous tumor of, 238; tumor
of, in cancer, 469.
Omodynia, 282.
Onychia in arthritis deformans, 285 ; in loco-
motor ataxia, 844; syphilitic, 168, 170.
Operation j9er se, elfects of, in epilepsy, 957.
Operation, tuberculosis after, 194.
Ophthalmia, gonorrheal with arthritis, 276.
Ophthalmoplegia, 794 ; externa, 794 ; interna,
795.
Opisthotonos, cervical, in infants, 864 ; in
tetanus, 163.
Opium, poisoning, diagnosis from ursemia, 740;
habit, 1005; smoking, etfect'; of, 1005.
Optic atrophy, 786 ; in ataxia, 842 ; primary,
786 ; secondary, 786.
Optic nerve and tract, diseases of, 783, 786.
Optic neuritis in abscess of brain, 904; in
brain-tumor, 919 ; in tuberculous meningitis,
204.
Orchitis, in malaria, 154; in mumps, 83 ; in-
terstitial, in syphilis, 179; in typhoid fever,
27 ; in variola, 49 ; syphilitic, 179 ; tubercu-
lous, 245 ; value of, in diagnosis, 245.
Orthotonos, in tetanus, 163.
Osteitis deformans, 992.
Osteo-arthropathie pncumiquc, 992.
Osteo-myelitis simulating acute rheumatism,
275.
Ovaries, tuberculosis of, 245.
Overexertion, heart affections due to, 639.
Oxalate-of-limc calculus, 765.
Oxaluria, 733.
INDEX.
10G9
Oxygen, inhalations of, in diabetic coma, 305.
Oxyuris venniouliiris, 102(3.
Oysters, poisoning by, 1015.
OzuMiu, 476.
Pachymeningitis cervicalis hypertrophica, 821.
Pachymeningitis haeniorrhagica, of cerebral
dura, 8G2; of spinal dura, 820.
PaijeVs disease of the nipple, 1023.
Palate, paralysis of, in dii)litheria, 107 ; in facial
paralysis, 799.
Palate, tuberculosis of, 240.
Palpitation of heart, 649.
Palsies, cerebral, of children (see Hemiplegia
OF Children), 906.
Palsy, lead, 1009.
Paludism (see Malarial Fever), 140.
Pancreas, diseases of, 457.
Pancreas, cancer of, 461 ; lesions of, in diabe-
tes, 297 ; cysts of, 460 ; haemorrhage into,
457 ; influence of, in diabetes, 296.
Pancreatic diabetes, 298.
Pancreatitis, acute hiemorrhagic, 458 ; chronic,
460 ; fat necrosis in, 459 ; gangrenous, 460 ;
suppurative, 459.
Papillitis, 786.
Paresthesia (numbness and tingling), in neu-
ritis, 778 ; in locomotor ataxia, 843 ; in tumor
of brain, 919 ; in primary combined sclerosis,
840.
Parageusis, 805.
Paralysis, acute ascending, 835 ; acute spinal,
of adults, 835 ; acute, of infants, 831 ; agitans,
926; alcoholic, 778; BelVs, 797; bulbar,
acute, 8f>0 ; chronic progressive, 861 ; of blad-
der, in myelitis, 829 ; of brachial plexus,
814 ; in chorea, 935 ; of circumflex nerve,
815; "crutch," 815; Cruveilhier''8^ 857; of
diaphragm, 814 ; after diphtheria, 106 ; Du-
chenne's^ 860 ; following epilepsy, 952 ; of
facial nerve, 797 ; of fifth nerve, 795 ; of
fourth nerve, 792 ; general, of the insane,
914 ; of hypoglossal nerve, 812 ; hysterical,
969 ; infantile, 831 ; " labio-glosso-laryngeal,
860 ; Landrjfs^ 835 ; of laryngeal abductors,
806 ; of adductors, 807 ; in lateral sclerosis,
837 : from lead, 1009 ; in locomotor ataxia, 845 ;
of long thoracic nerve, 815 ; in meningitis,
203, 866 ; of median nerve, 816 ; of musculo-
spiral nerve, 815 ; of oculo-motor nerves,
790 ; of olfactory nerve, 783 ; periodical, 985 ;
in progressive muscular atrophy, 859;
pseudo-hypertrophic, 996; radial, 815; of
rectum, in myelitis, 829 ; of recurrent laryn-
geal nerve, 806 ; secondary to visceral dis-
ease, 777 ; of sixth nerve, 793 ; of third
nerve, 790; of ulnar nerve, 810; of vocal
cords, 806.
Paramyoclonus multiplex, 999.
Paraphasia, 902.
Paraplegia, from alcohol, 778 ; from anajmia of
8i)inal cord, 825 ; from compression of cord,
851 ; dolorosa, 852 ; from haemorrhage into
cord, 826; from ergotism, 1016; hysterical,
969 ; in lathyrism, 1016 ; from myelitis, 829 ;
in pellagra, 1016 ; spastic, 836 ; spastica ccre-
bralis, 838 ; from spinal caries, 851 ; from
tumor of the cord, 856 ; in tabes, 845.
Paraplegic flasque, 837.
Parasites, diseases due to animal, 1022.
Parasites, pseudo-, 1050.
Paratyphlitis, 405.
" Parchment crackling" in rickets, 308.
Parenchymatous nephritis, 747.
Parieto-occipital region, brain tumors in, 920.
" Paris green," poisoning by, 1011.
Parkinsoii's disease, 926.
Parosmia, 782.
Parotid bubo, 328.
Parotitis, epidemic, 82 ; deafness in, 83 ; delir-
ium in, 83 ; orchitis in, 83.
Parotitis, symptomatic, 328 ; after abdominal
section, 329 ; in pneumonia, 524 ; in typhoid
fever, 20 ; in typhus fever, 42.
Paroxysmal hgemoglobinuria, 724.
Patellar-tendon reflex (see Knee-jerk).
Pectoriloquy, 227.
Pediculi, 1048 ; relations of, to tache bleiiatre,
16.
Pediculosis, 1048.
Pellagra, 1016.
Peliomata, 15.
Peliosis rheumatica, 317 ; in chorea, 938.
Pelvis of kidney, aftections of (see Ptelitis).
Pemphigoid purpura, 317.
Pemphigus neonatorum, 170.
Pennsylvania Hospital, 1017, 1018.
Pennsylvania Institution for Feeble-minded
Children, 906, 948.
Pentastomes, 1047.
Pepsin, tests for, in gastric juice, 347.
Pepsinogen, tests for, 347.
Peptic ulcer, 368.
Peptones in the urine, tests for, 728.
Peptonuria, 728.
Perforating ulcer of foot, 844.
Perforation of bowel in dysentery, 137; in ty-
phoid fever, 7, 22.
Periarteritis, gummatous, 179 ; nodosa, 683.
Pericardial friction, 583.
Pericarditis, acute plastic, 582; acute tubercu-
lous, 236; aphonia in, 585, chronic ad-
hesive, 589; chronic tuberculous, 236; de-
lirium in, 586 ; diagnosis of, 584, 587 ; dyspha-
gia in, 585 ; epidemics of, 582 ; epilei)sy in,
586 ; from extension of disease, 582 ; from
foreign body, 581 ; in chorea, 937 ; in fwtus,
I 582 ; in gout, 292 ; in rheumatism, 273 ; ham-
1070
INDEX.
orrhagic, 585 ; hyperpyrexia in, 583, 586
physical signs of, 583, 586; primary, 581
prognosis of, 587 ; pulsus paradoxus in, 585
secondary, 581 ; symptoms of, 583, 585 ; treat-
ment of, 588 ; with effusion, 584.
Pericardium, adherent, 589 ; Friedreich'' s sign
in, 590.
Pericardium, diseases of, 581 ; tuberculosis of,
235 ; air in, 591.
Perichondritis, laryngeal, in typhoid fever, 23 ;
in tuberculosis, 488.
Perihepatitis, 441.
Perinephric abscess, 773.
Periodical paralysis, 985.
Periplieral neuritis, 776.
Peristaltic unrest, 362, 973.
Peritonaeum, diseases of, 462.
Peritonaeum, fluid in, 469, 473 ; cancer of, 468 ;
new growths in, 468.
Peritoneum, tuberculosis of, 237 ; acute mil-
iary, 237; chronic, 237; chronic fibroid, 237.
Peritonaeum, tumor formations in tuberculosis
of, 238.
Peritonitis, acute general, 462, 471 ; chronic,
467, 473 ; chronic haemorrhagic, 468 ; diffuse
adhesive, 467 ; hysterical, 465 ; idiopathic,
462 ; in infants, 466 ; leukiemic, 702 ; local
adhesive. 467 ; localized, 466 ; perforative,
462; primary, 462; proliferative, 467; py-
aemie, 4G2 ; rheumatic, 462 ; secondary, 462 ;
septic, 462 ; tuberculous, 468.
Peritonitis, tuberculous, effects of operation on,
473.
Perityphlitis, 405.
" Perles " of Laennec^ 499.
Pernicious anaemia, 689.
Pernicious malaria, 152.
Peroneal type of muscular atrophy, 997.
Pertussis (see Whooping-cough), 84.
Pesta magna, 46.
PetcchiiR in epilepsy, 952; in relapsing fever,
44; in scurvy, 314; in small-pox, 53; in
typhus fever, 41.
Petit mal, 948, 952; in general paresis, 916.
Peyer's patches in typhoid fever, 5 ; in measles,
77 ; in tuberculosis, 241.
Phagocytosis, 111 ; in tuberculosis, 195,
Pharyngitis, 330; acute, 330; chronic, 330;
rctro-pharyngeal abscess of, 332; sicca, 331.
Pharynx, diseases of, 329.
Pharynx, acute infectious phlegmon of, 331 ;
hicmorrhage into, 329; hyperaemia of, 329;
(jcdema of, 330 ; paralysis of, 806 ; spasm of,
806; ulceration of, 331.
Philadelphia Hospital, relapsing fever at, 1844,
44; typhoid and typhus fever at, 2; typhus
epidemic in 1883, 40; statlHics of cerebro-
spinal fever, 95 ; of delirium tremens in, 1004.
Philadelphia Infirmary for Nervous Diseases,
statistics of chorea, 929 ; of hemiplegia and
diplegia in infants, 906 ; of epilepsy, 948.
Philadelphia, tuberculosis in city wards, 190;
yellow-fever epidemic in, 1793, 125.
Phlebitis of portal vein, 446.
Phlebo-sclerosis, 667.
Phloroglucin test for free IICl, 346.
Phosphates, alkaline, 734 ; earthy, 734.
Phosphatic calculi," 765.
Phosphaturia, 734.
Phosphorus poisoning, similarity of acute yel-
low atrophy to, 427.
Phrenic nerve, affections of, 813.
Phthiriasis, 1048.
Phthisical frame, Hippocrates's description of,
192.
Phthisis, acute pneumonic, 209.
Phthisis, chronic ulcerative, 214; acute pneu-
monia in, 232 ; arterio-sclerosis in, 233 ; basic
form of, 215 ; Bright's disease in, 230 ; of coal-
miners, 194, 555 ; chronic arthritis in, 233 ;
cough in, 220; endocarditis in, 228; diagno-
sis of, 230; distribution of lesions in, 214;
erysipelas in, 232 ; fatal haemorrhage in, 234 ;
fever in, 222 ; forms of cavities in, 216 ; gas-
tric symptoms of, 228 ; haemoptysis in, 222 ;
modes of death in, 234 ; modes of onset in,
218 ; physical signs of, 225 ; relation of fis-
tula in ano to, 241; sputum in, 220; sum-
mary of lesions in, 215; symptoms of, 219;
typhoid fever in, 232 ; vomiting in, 229.
Phthisis, fibroid, 231 ; fiorida, 212 ; renum, 243 ;
syphilitic, 175; of stone-cutters, 194, 553,
unity of, 196 ; ventriculi, 352.
Physiological albuminuria, 726.
Pia mater, diseases of, 822, 863.
Picric-acid test for albumen, 728.
Pigeon - breast, in rickets, 310; in mouth
breathers, 337.
Pigmentation of skin, from arsenic, 1011 ; from
phthiriasis, 1048; in Addisoji^s disease, 709,
710 ; in chronic pulmonary tuberculosis, 230 ;
in melanosis, 710 ; in peritoneal tuberculosis,
238.
Pigmentation of viscera in pellagra, 1017.
Pigs, tuberculosis in, 184.
Pin-worms, 1026.
Pitch, in cavities, change of, 227.
Pitting in small-pox, 51 ; measures to prevent,
58.
Pituitary body in acromegalia, 992.
Pityriasis versicolor, 230.
Plaques K surface r6ticuldc, 6.
Plaques jaunes, 879.
Plasmodium malariae, 143.
Plastic bronchitis, 502.
Pleura, diseases of, 558.
Pleura, echinococcus of, 1045 ; tuberculosis of
235.
INDEX.
1071
Pleural effusion, Bacclli's sign in, 502, 5G4;
compression of lunjr in, 55i) ; diagnosis of,
567 ; liajuiorrliagic, 5()G ; in scarlet fever, 7'2 ;
position of lieart in, 5G0 ; pseudo-cavernous
signs in, 5G2 ; purulent, 503 ; serous ellusion,
constituents of, 559 ; sudden death in, 563.
Pleural membranes, calcification of, 572.
Pleurisy, acute, 558 ; diaphragmatic, 566 ; en-
cysted, 567 ; etiology of, 558, 563 ; fibrinous,
558 ; interlobular, 567 ; pain in side in, 560 ;
plastic, 558 ; pleural friction in, 562 ; pulsat-
ing, 565, 677 ; sero-fibrinous, 558 ; treatment
of, 569 ; tuberculous, 235, 559, 566.
Pleurisy, chronic, 571 ; dry. 571 ; primitive
dry, 572 ; vaso-motor phenomena in, 573 ;
with etitusion, 571.
Pleurodynia, 282.
Pleuro-peritoneal tuberculosis, 235.
Pleurosthotonos in tetanus, 164.
Plica polonica, 1048.
Plumbism, 1007 ; in gout, 288 ; as a cause of
renal cirrhosis, 750 ; paralysis in, 1009.
Plymouth, epidemic of typhoid fever at, 4.
Pneumogastric aurte, 950.
Pneumogastric nerve, affections of, 805 ; cardiac
branches of, 808; gastric and oesophageal
branches of, 809 ; laryngeal branches of, 806 ;
pharyngeal branches of, 806; pulmonary
branches of, 808.
Pneumonia, acute croupous, 511 ; abscess in,
527 ; acute delirium in, 521 ; bleeding in,
530 ; clinical varieties of, 524 ; colitis, croupous,
in, 516 ; complications of, 522; crisis in, 517 ;
delayed resolution in, 527 ; diagnosis of, 528 ;
diagnosis from acute pneumonic phthisis,
211; diplococcua pneumoniae, 511, 512; en-
docarditis in, 516; engorgement of lung in,
514; epidemics of, 512, 525; etiology of, 511 ;
fever of, 517 ; fibroid induration in, 527 ;
gangrene in, 527 ; gray hepatization in, 515 ;
herpes in, 521 ; immunity from, 513; in dia-
betes, 525 ; in Infants, 525 ; in influenza, 525 ;
in old age, 525; meningitis in, 516; morbid
anatomy of, 514; mortality of, 527; pericar-
ditis in, 516; physical signs of, 519; prog-
nosis in, 526 ; pseudo-crisis in, 517 ; purulent
infiltration in, 515; recurrence of, 524; red
hepatization in, 514; relapse in, 524; resolu-
tion of, 515; terminations of, 526; treatment
of, 529.
Pneumonia, acute syphilitic, 176 ; apex pneu-
monia, 525; aspiration or deglutition, 537;
"cerebral," 522; chronic interstitial, 532,
534; chronic pleurogenous, 573; contusions,
512; double, 525; fibrinous, 511 ; hypostatic,
505; in malaria, 146; interstitial, of the root,
in sypliilirt, 175; in typhoid fever, 24; lar-
val, 525; lobar, 511; massive, 525; migra-
tory, 525 ; pleurogenous interstitial, 533 ; ty-
j)hoid pneumonia, 525 ; white, of the Actus,
175.
Pneumonitis, 511.
Pneumonokoniosis, 534, 553.
Pneumo-pcricardium, 591.
Pneumothorax, 574 ; after tracheotomy, 580 ;
causes of, 574 ; chronic, 577 ; Ilippocratic suc-
cussion in, 576 ; morbid anatomy of, 575 ; in
phthisis, 218; from muscular effort, 575;
ISTcoda's resonance in, 575 ; symptoms of, 575;
treatment of, 577.
Pneumotoxin, 513.
Pneumo-typhus, 24.
Podagra, 287.
Pododynia, 961.
Poikilocytosis, 692.
Poisoning, by leucomaines, 1012; by meat,
1013; by ptomaines, 1012; by sewer-gas,
264.
Poliomyelitis, acute and subacute, in adults,
835.
Poliomyelitis anterior, acute, 831 ; etiology of,
831 ; morbid anatomy of, 832 ; prognosis of,
833 ; symptoms of. 832.
Poliomyelitis anterior chronica, 857.
Polyneuritis, acute febrile, 777.
Polysarcia, 1019.
Polyuria (see Diabetes Insipidus), 305.
Polyuria, in abdominal tumors, 306; in hys-
teria, 307.
Pons, lesions of, 898 ; tumors of, 920.
Popliteal nerve, external, 818 ; internal, 818.
Porencephalus, 907.
Pork in relation to trichinosis, 1028.
Portal vein, 429 ; thrombosis of, 429 ; suppura-
tion in, 446.
Post-epileptic conditions, 952.
Post-hemiplegic chorea, 908 ; epilepsy, 908,
950 ; movements, 908.
Post-mortem movements in cholera bodies, 120.
Post-pharyngeal abscess, 332.
Post-typhoid, anaemia, 17; elevations of tem-
perature, 13.
PoWs disease, 851.
Poumon, ulceres du, 535, 555.
Pregnancy, and acute yellow atrophy, 426 ; and
chorea, 931 ; and phthisis, 247.
Presystolic nmrmur, 616.
Priapism in leuktcmia, 702.
Prickly heat (see Urticaria).
Probefriihstuck, 345.
Procession caterpillar, effects of, 1050.
Professional spasms, 963.
Proglottis of tienia, 1036.
Progressive muscular atrophy, 857.
Progressive pernicious anaiuiia, 689; blood in,
692; diagnosis of, 694; etiology of, 689 ; mor-
bid anatomy of, 691 ; prognosis of, 694 ; symp-
toms of, 691 ; treatment of, 696.
1072
INDEX.
Propeptonc, 728.
rrophylaxis, against cholera, 123; against
scurvy, 315 ; against tuberculosis, 247 ; against
taenia, 1038 ; against trichina, 1031 ; against
yellow fever, 128.
Prosopalgia, 960.
Prostate, tuberculosis of, 245.
Protozoa, diseases caused by, 1022.
Prune-juice expectoration, 557.
Pruritus from diabetes, 300 ; from uraeniia, 739.
Pseudo-angina pectoris, 657, 658, 974.
Pseudo-apoplectic seizures in fatty heart, 644.
Pseudo-buibar paralysis, 861.
Pseudo-cavernous signs, 228, 562, 568.
Pseudo-cyesis, 970.
Pseudo-diphtheritic processes, 101.
Pseudo-hypertrophic muscular paralysis, 996.
Pseudo-leukaemia, 704.
Pseudo-parasites, 1050.
Pseudo-ptosis, 791.
Pseudo-rabies, 162.
Pseudo-rheumatic aflfections, 279.
Pseudo-scl^rose en plaques, 914.
Psorospermiasis, 1022; cutaneous, 1023; in-
ternal, 1022.
Ptomaine poisoning, 1012.
Ptomaines in septicaemia, 115.
Ptosis, forms of, 791 ; hysterical, 791 ; in ataxia,
842; pseudo-, 791;
Ptyalism, 327, 328.
Pulex, irritans, 1049 ; penetrans, 1049.
Pulmonary (see Lungs).
Pulmonary apoplexy, 508.
Pulmonary artery, sclerosis of, 667 ; perforation
of, G76.
Pulmonary haemorrhage, 506 ; treatment of, 509.
Pulmonary orifice, congenital lesions of, 661 ;
valves, lesions of, 620.
Pulsating pleurisy, 565, 677.
Pulsation, dynamic, of aorta, 677.
Pulse, alternate, 651 ; under influence of digi-
talis, 625 ; intermittent, 650 ; irregular, 651 ;
bigeminal, 651, 652 ; paradoxical, 650.
Pulse, capillary (see Capillary); Corrigan?s^
606 ; water-hammer, 606.
Pulse, slow, in tuberculous meningitis, 203 ; in
jaundice, 430 (see Braoiiycardia, 653).
Pupil (see Iuidoplegia), 792.
Pupil, Argyll- Robertson^ 792.
Pupillary inaction, hemiopic, 789.
I'upils, unequal, 792 ; in general paresis, 916 ; in
tabes, 842.
Purpura, 316 ; arthritic, 317 ; cachectic, 316 ; di-
agnosis of, 319; fulminans, 319; infectious,
316; mechanical, 317; neurotic, 317; pelio-
pia rheumatica in, 317 ; haemorrhagica, 318;
Biinplex, 317 ; symptomatic, 316; toxic, 316;
treatment of, 320; urticans, 317; variolosa,
52.
Purpuric oedema, 318.
Pustule, malignant, 157.
Pyaemia, 116; arterial, 116, 599; idiopathic
116.
Pyelitis, 758 ; diagnosis of, 761 ; intermittent
fever in, 760 ; morbid anatomy of, 759 ; prog-
nosis of, 762; pyuria in, 760; symptoms of,
760 ; treatment of, 762.
Pyelonephritis, 758.
Pyelothrombosis, 429.
Pylephlebitis adhesiva, 429.
Pylephlebitis, in dysentery, 137 ; in pyaemia,
116 ; suppurative, 429, 447.
Pyonephrosis, 758.
Pyo-pneumothorax, 574.
Pyo-pneumothorax subphrenicus, 369, 576 ; in
perforative appendicitis, 408.
Pyramidal tract, course of fibres of, 891.
Pyrosis, 353.
Pyuria, 729.
Quarantine against yellow fever, 128 ; against
cholera, 123.
Quartan ague, 151.
Quebec, cholera at, in 1832, 118.
Quinine rash, 68, 74.
Quintan ague, 151.
Quinsy (see Tonsillitis, Suppurative).
Quotidian ague, 150.
Rabies, 159 ; etiology of, 159 ; morbid anatomy
of, 161 ; preventive inoculation in, 161 ;
symptoms of, 160; treatment of, 161.
Rachitic bones, 308.
Rachitis (see Rickets), 307.
Radial paralysis, 815.
Rag-picker's disease (see Wool-sorter's Dis-
ease), 158.
Railway brain, 981.
Railway spine, 981.
Rainey's tubes, 1022.
Rashes, from drugs, 74, 316; in glanders, 260;
in measles, 78; in relapsing fever, 44; in
rubella, 81 ; in scarlet fever, 69 ; in small-pox,
50, 51 ; in syphilis, 168 ; in typhoid fever, 15 ;
in typhus fever, 41 ; in pytemia, 117 ; in
vaccination, 63 ; in varicella, ^Q.
Ray-fungus (actinomyces), 261.
Raynaud's disease, 987 ; epilepsy in, 988 ; haem-
oglobinuria in, 988 ; pathology of, 989.
Reaction of degeneration, 780, 799.
Recrudescence of fever in typhoid fever, 14.
Rectal crises in tabes, 844.
Rectum, irritable, 973 ; stricture of, 178 ; syph-
ilis of, 178.
Recurrent laryngeal nerve, paralysis of, 806.
Red softening of brain, 879.
Reduplication of heart-sounds, 651.
Redux crepitus, 520.
Reflex epilepsy, 950.
INDEX.
1073
Eeflexcs in asccndinf]^ paralysis, 836 ; in cere-
bral haiuiorrliage, 875 ; in locomotor ataxia,
842 ; in polio-myelitis acuta, 833 ; in spastic
paraplegia, 837 ; in hysterical paraplegia, 839,
969; in progressive muscular atrophy, 859.
Eelapse in typhoid fever, 29.
Relapsing fever, 43 ; spirillum of, 44.
Remittent fever, 151.
Ren mobilis, 717.
Renal calculus, 765.
Renal, colic, 766 ; sand, 765.
Resolution in pneumonia, 526.
Resonance, amphoric, 227, 575 ; tympanitic, 227,
561, 575.
Respiratory system, diseases of, 474.
Rest treatment, 977 ; in aneurism, 678.
Retina, lesions of, 783.
Retinal hyperaesthesia, 785.
Retinitis, albuminuric, 784; in anaemia, 784;
in malaria, 784 ; leuksemic, 784 ; pigmentosa,
784 ; syphilitic, 168, 784.
Retraction of head in meningitis, 203, 866.
Retroperitoneal abscess, 408.
Retroperitonaeum, htemorrhage into, 49, 457.
Retropulsion in paralysis agitans, 928.
Revaccination, 61.
Rhabdo-rayoma of kidney, 770.
Rhabdonema intestinale, 1036.
Rhagades, 170.
Rheumatic fever, 270 ; age in, 270 ; cerebral
complications of, 274 ; diagnosis of, 275 ; en-
docarditis in, 273; etiology of, 270; fibrous
nodules in, 275 ; germ theory of, 271 ; liered-
ity in, 271 ; hyperpyrexia in, 273 ; metabolic
theory of, 271 ; morbid anatomy of, 271 ;
nervous theory of, 271 ; pericarditis in, 273 ;
purpura in, 274; sex in, 270; symptoms of,
272 ; treatment of, 276.
Rheumatic gout (see Akthritis Deformans).
Rheumatic nodules, 275.
Rheumatism, chronic, 278 ; etiology of, 278 ;
morbid anatomy of, 278 ; prognosis of, 278 ;
symptoms of, 278 ; treatment of, 278.
Rheumatism, muscular, 281.
Rheumatism, subacute, 273.
Rheumatoid arthritis (see Arthritis Defor-
mans).
Rhinitis atrophica, 475 ; hypertrophica, 475 ;
simplex, 475; syphilitic, 170.
Ribs, resection of, in empyema, 571.
Rice-water stools, 122.
Rickets, 307 ; acute, 311, 315 ; etiology of, 307 ;
fffttal, 307; morbid anatomy of, 308 ; progno-
sis of, 311 ; Hymptoms of, 309 ; treatment of,
312.
Rigidity, early, in hemiplegia, 873.
Rigidity, late, in liemiplogia, 875.
Rigors, in abscess of brain, 904; in abscess of
liver, 448; in ague, 147 ; in pyieinia, 117; in
pneumonia, 517 ; in pyelitis, 760; in tuber-
culosis, 219.
Risus sardonicus, 163.
Riverside Hospital, New York, typhus epi-
demic, 1881, 43.
Rock-fever, 266.
Eomber(fs symptom, 843.
Root-nerve symptoms in compression para-
plegia, 851.
Root-zone of Charcot^ affection of, in tabes, 841.
Rosary, rickety, 309.
Roseola (see Rose Rash of Typhoid), 15.
" Rose cold," 477.
Rose rash in typhoid fever, 15.
Rotation in epilepsy, 951.
Rotatory spasm in hysteria, 971.
Rotheln, 81.
" Rough-on-rats," poisoning by, 1011.
Round-worms, 1025.
Rub (see Friction).
Rubella, 81.
Rubeola notha, 81.
Rumination, 362.
Running pulse in typhoid fever, 17.
Russian fever, 88.
Saccharomyces albicans, 325.
Sacral plexus, lesions of, 817.
St. Vitus's dance, 929.
Saline injections, intravenous, in diabetic
coma, 305 ; subcutaneous, in cholera, 124.
Salaam convulsions, 945, 970.
Saliva, arrest of, 328 ; hypersecretion of, 328.
Salivary glands, diseases of, 328 ; inflammation
of, 328.
Salivation (see Ptyalism), 327, 328 ; in small-
pox, 52 ; in bulbar paralysis, 861.
Salpingitis, tuberculous, 239, 245.
Saltatoric spasm, 943.
Sanitaria for tuberculosis, 252.
Sapramia, 114.
Saranae Sanitarium, 251.
Sarcina ventriculi, 365 ; in lung cavities, 222.
Sarcoma, of brain, 918 ; of kidney, 770 ; of
liver, 453; of lung, 556; mediastinal, 578;
melanotic, 453.
Sarcoptes hominis, 1047.
Saturnine neuritis, 779.
Saturnism, 1007.
Sausage poisoning, 1013.
Scapulodynia, 282.
Scarlatina miliaris, 69.
Scarlatina sine eruptione, 71.
Scarlatinal nephritis, 71.
Scarlet fever, 67 ; anginose form, 71 ; ataxic
form, 71 ; complications and se(iuelie, 71 ;
contagiousness of, 67 ; desquamation in, 70 ;
diagnosis of, 73 ; eruiition in, 69 ; etiology of,
67 ; huiinorrhagic form, 71 ; incubation in,
1074
INDEX.
60 ; invasion in, 69 ; maliijnant, 71 ; morbid
anatomy of, 68 ; prognosis of, V4 ; puerperal,
68 ; surgical, 68 ; treatment of, 75.
Schonleiu\'i disease, 317.
School-made chorea, 932.
Sciatica, 818.
Sciatic nerve, 817.
Scirrhus cancer of stomach, 377 ; of pancreas,
461.
Sclerema in cholera infantum, 393.
Selerodactyle, 992.
Scleroderma, 993.
Sclerose en plaques, 913.
Sclerosis, cerebro-spinal, 911, 913 ; degenera-
tive, 911 ; developmental, 912 ; inflamma-
tory, 912 ; syphilis as a cause of, 169.
Sclerosis, lateral, 837.
Sclerosis, posterior spinal (see Locomotor
Ataxia), 840 ; in chronic ergotism, 1016.
Sclerosis, primary combined, 840.
Sclerosis in tubercles, 195.
Sclerosis, renal, 749. •
Sclerostomum duodenale, 1031.
Scolices of echinococcus, 1042.
Scorbutus, 312.
Scrivener's palsy, 963.
Scrofula, 204 ; alleged protective inoculation
by, 206.
Scrofulous pneumonia, 197, 210.
Scurvy, 312; diagnosis of, 315; etiology of,
312; in children, 315; diagnosis from rick-
ets, 315 ; morbid anatomy of, 313 ; prognosis
of, 315; prophylaxis of, 315; symptoms of,
314; treatment of, 316.
Scybala, 421.
Seasonal relations, of chorea, 930 ; of malaria,
141 ; of pneumonia, 511 ; of rheumatism, 270.
Secondary contracture in hemiplegia, 875.
Secondary deviation, 793.
Secondary fever of small-pox, 51.
Self-limitation in tuberculosis, 246.
Semilunar space of Traube^ 562.
Semilunar valves, aortic, incompetency of, 602.
Senile emphysema, 549.
Sensation, painful, loss of, in syringomyelia,
850.
Sensation, retardation of, in ataxia, 843.
Sensory centres and paths in brain and cord,
895.
Septicaemia, 114; progressive, 115.
Serratus palsy, 815.
Sewer-gas and tonsillitis, 332.
Sewer-gas and diplithcfia, 99.
Sewer-gas poisoning, effects of, 264.
Sexes, proportion of, affected with acute yel-
low atrophy, 426 ; in chlorosi.s, 686; in cho-
rea, 929 ; in exophthalmic goitre, 712 , in
general paresis, 914 ; in hicmophilia, 320.
Sex, influence of, in heart-disease, 621.
Sextan ague, 151.
Shaking palsy, 926.
Shell-fish, poisoning by, 1014.
Ship-fever, 39.
Shock as a cause of traumatic neuroses, 981.
Shock, death from, in acute obstruction, 417.
Sick headache, 957.
Siderosis, 553, 555.
Signal symptom (in cortical lesions), 897.
Sinus thrombosis, 885 ; in chlorosis, 885 ; and
pyaemia, 886 ; secondary, in ear-disease, 885.
Sixth nerve, paralysis of, 793.
Skin, itching of, in ur.'cmia, 739.
Skoda's resonance in pleural ett'usion, 561 ; in
pneumonia, 519.
Skull, of congenital syphilis, 171 ; of hydro-
cephalus, 923; of rickets, 310.
Small sciatic nerve, 817.
Small-pox, 46 ; complications of, 55 ; confluent
form, 51 ; contagiousness of, 46 ; diagnosis
of, 56 ; discrete form, 51 ; eruption in, 51 ;
etiology of, 46 ; hemorrhagic, 52 ; inocula-
tion in, 46 ; morbid anatomy of, 48 ; progno-
sis of, 56 ; symptoms of, 49 ; treatment of,
58 ; vaccination in, 46.
Smell, affections of sense of (see Olfactory
Nerve), 782.
Snake-virus, purpura caused by, 316.
Snuffles, 170.
Softening of brain, 878.
Soil, influence of, in cholera, 120 ; in tubercu-
losis, 193 ; in typhoid fever, 5.
Solvent treatment of renal calculi, 769.
Soor, 325.
Sordes, 20.
Sore throat, 330.
tSoya bread, 304.
Spasms, in ergotism, 1015 ; in hydrophobia,
160 ; in hysteria, 969 ; of face, 800 ; of muscles,
after facial paralysis, 799 ; professional, 963 ;
saltatoric, 943.
Spasm, lock, in writer's cramp, 964.
Spasmodic wryneck, 810.
Spastic paraplegia, 836 ; in children, 838.
Specific infectious diseases, 1.
Spectra, fortification, 958.
Speech (see Aphasia), 898.
Speech, in adenoid vegetations, 337 ; in bulbar
paralysis, 861 ; in insular sclerosis, 914 ; in
general paralysis, 916; in hereditary ataxia,
849; in paralysis agitans, 927.
Speech, scanning, in insular sclerosis, 914.
Spes phthisica, 229.
Spina bifida, involvement of cauda equina in,
855.
Spinal accessory nerve, paralysis of, 809.
Spinal apoplexy, 826.
Sjnnal concussion, effects of, 982.
Spinal L'ord, diseases of, 820.
INDEX.
1075
Spinal cord, acute affections of, 828 ; antcniia
of, 825 ; chronic affections of, 836 ; chronic
leptomeningitis of, 823 ; compression of, 851 ;
congestion of, 825 ; embolism and thrombo-
sis of vessels of, 825 ; endarteritis of vessels
of, 825 ; fissures in, 827 ; hoemorrhage into,
826 ; leptomeningitis of, 822 ; localization of
functions of, 887 ; pachymeningitis of, 820 ;
sclerosis, primary combined, of, 840 ; syphilis
of, 174 ; tuberculosis of, 243 ; tumors of, 855 ;
unilateral lesions of, 853.
Spinal epilepsy, 838.
Spinal irritation, 979.
Spinal membranes, haemorrhage into, 824.
Spinal neurasthenia, 979.
Spinal paralysis, atrophic, 831.
Spine-chair of J. K. Mitchell^ 853.
Spino - muscular segment (of motor path),
lesions of, 893.
Spirals, Curschmann's^ 500, 503.
Spirillum of relapsing fever, 44.
Spirochaete Obermeicri, 44.
Splanchnoptosis, 719.
Spleen, amyloid degeneration of, in syphilis,
177 ; in tuberculosis, 218.
Spleen, in ague, 145, 154; in anthrax, 158 ; in
cirrhosis of liver, 443 ; in HodghirCs disease,
705 ; hydatid of, 1043 ; in leukaemia, 702 ; in
rickets, 308, 311 ; in acute tuberculosis, 199 ;
in typhoid fever, 8 ; in typhus, 40.
Spleen, floating, excision of, 703.
Spleen, enlargement of, in congenital syphilis,
170, 172 ; in malaria, 144.
Spleen, excision of, in hypertrophy, 703 ; in
leukaemia, 703.
Spleen, puncture of, 31.
Spleen, rupture of, in malaria, 144 ; in typhoid
fever, 8, 23.
Splenectomy, statistics of, 703.
Splenic fever, 156.
Splenization of lung, 212, 538.
Spondylitis deformans, 286.
Sporozoa, 1022.
Sputa, albuminoid, after aspiration of chest,
570; alveolar cells in, 491, 504; amoeba coli
in, 138; in cancer of lung, 557; haematoidin
crystals in, 496 ; in anthracosis, 555 ; in
a.sthma, 499 ; in bronchiectasis, 496 ; in
acute bronchitis, 491 ; in chronic bronchitis,
493 ; in putrid bronchitis, 494 ; in gangrene
of lung, 551.
Sputa, in phthisis, 220; in pneumonia, 519; in
acute pulmonary tuberculosis, 200; prune-
juice, 557 ; uric-acid crystals in, 290.
Staphylococci, in diphtheria, 101 ; in endocar-
ditis, 596; in peritonitis, 463; in pneumonia,
515 ; in pyaemia, 116 ; in septicaemia, 114.
Staphylococcus pyogenes albus, 463.
Staphylococcus pyogenes aureus, 463.
68
Starch, test for, in gastric contents, 347.
Status cpilepticus, 951.
Stcarrluca, 4(»1.
StellwmfH sign, 713.
Stenocardia, 655.
Stenosis, of aortic orifice, 608 ; of mitral orifice^
614 ; of pulmonary orifice, 620, 661 ; of tricus-
pid orifice, 619.
Stercoraceous vomiting, 416.
Stertor, in apoplexy, 873.
Stiff neck, 281.
Stigmata, in hysteria, 974 ; in purpura, 317.
Stitch in side in pneumonia, 517, 560.
Stolidity of face in general paresis, 916.
Stomach, absorptive power of, tests for, 348 ;
atrophy of, 352.
Stomach, cancer of, 376 ; absence of free HCl
in, 379 ; diagnosis from gastric ulcer and
chronic gastritis, 382 ; etiology of, 376 ; haem-
orrhage in, 379 ; morbid anatomy of, 376 ;
vomiting in, 379.
Stomach, diseases of, 344.
Stomach, dilatation of, 364 ; tetany in, 365.
Stomach, examination of contents of, 345 ; for-
eign bodies in, 384; haemorrhage from, 371,
385; hair tumors in, 384; methods of clini-
cal examination, 344 ; motor power of, test for,
347 ; neuroses of, 359 ; non-cancerous tumors
in, 384 ; position and size of, 344 ; size of,
method of deteriuining, 366 ; tuberculosis of,
240; ulcerof, 368; washing out of (lavage), 357.
Stomatitis, 323 ; acute, 323 ; aphthous, 323 ; fet-
id, 324 ; follicular, 323 ; gangrenous, 326 ;
mercurial, 327 ; parasitic, 325 ; ulcerative,
324 ; vesicular, 323.
Stone-cutter's phthisis, 194, 553.
Stools, of acute yellow atrophy, 427 ; of chol-
era, 122; of dysentery, 131, 134, 136; of ty-
phoid fever, 20 ; in haematemesis, 387 ; of ob-
structive jaundice, 424.
St. Thomas's Hospital, statistics of pneumonia
at, 528.
St. Petersburg Foundling Asylum, statistics of
tuberculosis at, 233.
Strabismus, 793 ; as an early symptom ot
tabes, 842.
Strangulation of bowel, 413, 418.
" Strawberry " tongue in scarlet fever, 69.
Stricture of bile-duct, 437.
Stricture of colon, cancerous, 415.
Stricture of intestine, 415 ; after dysentery,
137, 415 ; after tuberculous ulcer, 241.
Stricture of oesophagus, 341.
Stricture of pylorus, 364.
Streptococci in diphtheria, 101 ; in empy-
ema, 564 ; in endocarditis, 596 ; in pneu-
monia, 515 ; in peritonitis, 463 ; in pyicinia,
116; in scarlet fever, 68; in septicaemia, 114;
in tonsillitis, 333.
1076
INDEX.
Streptococcus of Fehleisen in erysipelas, 111.
Streptococcus pyogenes, 463 ; in erysipelas. 111.
Strongylus, annatus, 1031 ; duodcnalis, 1031.
Stupes, turpentine, method of application, 36.
Stuttering in mouth-breathers, 337.
Styrian peasants, arsenical liabit in, 1012.
Subclavian artery, murmur in, and throbbing
of, in phthisis, 227.
Subsultus tendinum in typhoid fever, 25.
Succussion, Ilippocratic, 576.
Succussion splash in dilated stomach, 366.
Sucklings, tuberculosis in, 187.
Sudamina in typhoid fever, 16.
Sudden death, in aortic insufficiency, 607 ; in
coronary artery disease, 640 ; in pleural effu-
sion, 563 ; in typhoid fever, 31.
Sudoral form of typhoid fever, 16.
Sugar in the urine, 298.
Sulphocyanides in excess in saliva in rheuma-
tism, 273.
Sunstroke, 1017 ; aftcr-eft'ects of, 1018 ; treat-
ment of, 1019.
Suppurative nephritis, 759.
Surgical kidney, 759.
Suspension in compression paraplegia, 853.
Sweating, in acute rheumatism, 272; in ague,
150 ; in diabetes, 300 ; in phthisis, 225 ; in
pyaemia, 117 ; in typhoid fever, 16 ; in ulcera-
tive endocarditis, 597; profuse, in rickets,
309 ; unilateral, in cervical caries, 852 ; uni-
lateral, in aneurism, 676.
Sweating sickness, 268.
Sydenham's chorea, 929.
Symmetrical gangrene, 987.
Sympathetic ganglia, in Addison's disease,
709 ; in exophthalmic goitre, 712.
Sympathetic nerve fibres (see Vaso-motok).
Syncopal ague, 153.
Syncope, fatal, in diphtheria, 107 ; in cardiac
disease. 607, 622, 644; in phthisis, 234; in
pleural effusion, 563.
Syncope, local, 987.
Synovial rheumatism (see Gonorrheal Rheu-
matism), 279.
Synovitis, gonorrhoeal, 280.
Synovitis, symmetrical, in congenital syph-
ilis, 171.
Syphilides. macular, 168 ; papular, 168; pustu-
lar, 168 ; squamous, 108 ; the late, 169.
Syphilis, 165; accidental infection in, 165;
acquired, 167 ; amyloid degeneration in,
169; congenital, 169; diagnosis of, 179; eti-
ology of, 165; gummata in, 166; hereditary
transmission of, 165; modes of infection in,
165; morbid anatomy of, 166 ; of brain and
cord, 172 ; of circulatory system, 178 ; of
digestive tract, 178 ; of liver, 176 ; of lung,
174 ; orchitis in, 179; primary stage of, l'i7 ;
prophylaxis of, 180; renal, 179; secondary
stage of, 167; symptoms of, 169; tertiary
stage of, 109 ; treatment of, 181 ; visceral, 172.
Syphilis hremorrhagica neonatorum, 170.
Syphilis hereditaria tarda, 187.
Syphilis and locomotor ataxia, 841.
Syphilis and dementia paralytica, 173, 917.
Syphilitic arteritis, 178.
Syphilitic encephalopathy, 173.
Syphilitic fever, 167.
Syphilitic phthisis, 175.
Syringo-myelia, 849 ; with haemorrhage, 826.
Tabes, diabetic, 301.
Tabes mesenterica, 208.
Tabes dorsalis (see Locomotor Ataxia), 840 ;
in chronic ergotism, 1016.
Tabes dorsalis spasmodique, 836.
Taches bleuktres, 15, 1049 ; relation to pediculi,
15, 1049.
Tachc c^rebrale, 16, 203.
Tachycardia, 652.
Tactile fremitus, in emphysema, 548 ; in pneu-
monia, 519 ; in pleural effusion, 561 ; in pneu-
mothorax, 575; in pulmonary tuberculosis,
220 ; at right apex, 225.
Taenia echinococcus, 1041.
Taenia elliptica; T. cucumerina ; T. flavopunc-
tata; T. nana; T. Madagascariensis, 1037.
Taenia saginata or mediocanellata, 1037.
Taenia solium, 1036.
Tape- worms, 1036 ; treatment of, 1038.
Taste, disturbances of, 805 ; tests for sense of,
805.
Techomyza fusca, 1050.
Teeth, actinomyces in, 203; looseness of, in
scurvy, 314; erosion of, 327; Hutchinson'' s^
171, 327; of infantile stomatitis, 327.
Teichopsia, 958.
Telegrapher's cramp, 963.
Temperature sense, loss of, in syringo-myelia,
850 ; in Morvan^s disease, 850.
Temperature, subnormal, in acute alcoholism^
1001; in apoplexy, 873; in heat exhaustion,
1017; in malaria, 153 ; in pulmonary tubercu-
losis, 224 ; in tuberculous meningitis, 199 ; in
uraemia, 739.
Temporal lobe, centre for hearing in, 801 ;
tumors of, 920.
Tender points in neuralgia, 960; in hysteria,
971.
Tendon-reflexes (see Reflexes).
Tertian ague, 150.
Testes, tuberculosis of, 245 ; syphilis of, 179 (see
also Orchitis).
Tetanin, 163.
Tetanus, 162; bacillus of, 163; diagnosis of,
104 ; etiology of, 162 ; prognosis of, 164 ; symp-
toms of, 103; treatment of, 164.
Tetanus hydrophobicus, 164.
INDEX.
1077
Tetany, 965 ; after thyroidectomy, 965 ; diag-
nosis oi\ 906 ; epideiuie or rliounuitic, 965 ; in
dilatation of tlic stomach, 365, 965 ; in myx-
cedema, 965 ; rarity of, in America, 965 ; symp-
toms of, 966 ; treatment of, 966 ; varieties of,
965.
Tetrodon, poisoning by, 1015.
Therapeutic test in syphilis, 180.
Thermic fever, 1017 ; continued, 1019.
Thermic sense, loss of, in syringo-myelia, 850.
Third nerve, diseases of, 790.
Third nerve, recurring paralysis of, 791 ; signs
of paralysis of, 791.
Third ventricle, tumors in, 920.
Thirst in diabetes, 299.
Thomseri's disease, 998.
Thoracic duct, tuberculosis of, 198.
Thorax, deformity of, in mouth-breathers, 337 ;
in rickets, 309.
Thorax in emphysema, 548 ; in phthisis, 192,
225.
Thorn-headed worms, 1036.
Thread-worm, 1026.
Thrombi in veins in typhoid fever, 19.
Thrombi in heart, 615; in diphtheria, 103; in
pneumonia, 516,
Thrombi, marantic, 885.
Thrombosis of cerebral arteries, 878 ; of cere-
bral sinuses, 885 ; of cerebral veins, 885.
Thrush, 325.
Thymic asthma, 486, 580.
Thymus gland, in acromegalia, 991 ; enlarge-
ment of^ 580 ; sudden death in, 580.
Thyroid gland, diseases of, 711.
Thyroid gland, abeiTant or accessory tumors
of, 712 ; absence of, in cretins, 714 ; adenoma-
ta of, 712; cancer of, 712; in exophthalmic
goitre, 712; in goitre, 711; in myxoedema,
714; sarcoma of, 580, 712; tumors of, 712.
Tic convulsif, 943.
Tic douloureux, 960.
Ticks, 1048.
Tinnitus aurium, 802.
Tintement m^tallique, 632.
Tobacco, influence of, on the heart, 629, 634, 649,
Tongue, atrophy of, 812; in bulbar paralysis,
861 ; spasm of, 813 ; tuberculosis of, 240.
Tongue, tremor of, in general paresis, 916;
ulcer of frainum in whooping-cough, 85.
Tonsillitis, 332 ; acute, 332; albuminuria iu,
334; endocarditis in, 334; in the newly mar-
ried, 333.
Tonsillitis, chronic, 335; follicular, 332; lacu-
nar, 332 ; suppurative, 334; and rlieumatism,
332.
Tonsils, diseases of, 332,
Tonsils, abscess of, 334 ; calculi of, 338 ; cheesy
maHHCH in, 338 ; enlarged, 336 ; tuberculosis
of, 240.
Tophi, 291.
Toronto General Hospital, statistics of typhoid
fever at, 3.
Torticollis, 281, 810; congenital, 810; facial
asymmetry in, 810 ; spasmodic, 810 ; treat-
ment of, 811.
Toxalbumin in diphtheria, 101.
Toxines, 1012; in septicujmia, 115.
Tracheal tugging, 674.
Trance in hysteria, 969.
Trauhe's semilunar space, 562.
Trauma as a factor, in delirium tremens, 1003 ;
in neurasthenia, 981 ; in pneumonia, 512 ; in
tuberculosis, 193.
Trematodes, diseases caused by, 1024.
Trcixibles in cattle, 266.
Tremor, alcoholic, 929, 1002 ; hereditary, 929 ;
hysterical, 929, 971 ; in exophthalmic goitre,
713 ; in paralysis agitans, 927 ; lead, 1010 ;
senile, 929; simple, 929; toxic, 929; voli-
tional, in insular sclerosis, 913.
Trichina spiralis, distribution of, 1026 ; statis-
tics of^ in American hogs, 1028 ; in Germany,
1028.
Trichiniasis, 1026 ; diagnosis of, 1030 ; statis-
tics of, in America, 1029.
Trichocephalus dispar, 1035.
Trichter-brust, 225.
Tricuspid valve, insufficiency of, 618.
Tricuspid orilice, stenosis of, 619.
Trigeminus (see Fifth Nerve).
Tronnner's test, 299.
Tropajolin test for free acid, 346.
Trophic disorders, 987.
Trousseau's phenomenon in tetany, 966.
Tubal pregnancy, ruptured, simulating perito-
nitis, 465.
Tubercle bacilli, 185, 220.
Tubercle, diffuse infiltrated, 196, 216 ; miliary^
195 ; changes in, 195 ; structure of, 195.
Tubercles, miliary, in chronic phthisis, 215.
Tubercula dolorosa, 782.
Tuberculin, 186.
Tuberculosis, acute, 197; general or typhoid
form, 198 ; meningeal form, 201 ; pulmonary
form, 200.
Tuberculosis, bacillus of, 185, 220 ; changes pro-
duced by bacillus, 195 ; chronic miliary, 215 ;
conditions influencing infection, 192; con-
genital, 187 ; dietetic treatment of, 252 ; dis-
tribution of the tubercles in, 194; duration
of pulmonary form of, 247 ; etiology of,
184 ; general measures in treatment of, 250 ;
hereditary transmission of, 187 ; individual
prophylaxis in, 248 ; infection by meat, 191 ;
infection by milk, 191 ; infection through
the air, 189; inoculation of, 188; in infants,
233 ; in old age, 233 ; medicinal treatment of,
253 ; modes of death in pulmonary, 234 ; modes
1078
INDEX.
of infection in, 187 ; natural or spontaneous
cure of, 249 ; of alimentary canal, 239 ; of
arteries', 24G ; of brain and cord, 242 ; of Fal-
lopian tubes, 245 ; of genito-urinary system,
243 ; of kidneys, 243 ; of liver, 242 ; of lymph
glands, 204; of ovaries, 245 ; of pericardium,
235 ; of peritonaeum, 237 ; of pleura, 235 ; of
prostate, 245 ; of serous membranes, 235 ;
of testes, 245 ; of ureters and bladder, 244 ;
of uterus, 245 ; of vesiculae serainales, 245 ;
pregnancy, influence of, in, 247 ; prognosis
of, 246 ; prophylaxis in, 247 ; pulmonary,
208 ; specific treatment of, 252 ; treatment of,
249, 254.
TufnelVs treatment of aneurism, 678.
Tumors of brain, 918.
Tunnel anaemia, 1032.
Tympanites, in intestinal obstruction, 417 ; in
peritonitis, 463 ; in tuberculous peritonitis,
238 ; in typhoid fever, 23 ; as a cause of sud-
den lieart-failure, 403 ; in the constipation
of infants, 422.
Typhlitis, 405.
Typhoid fever, 1 ; abortive form, 28 ; afebrile,
15, 29 ; ambulatory form, 13, 28 ; anaemia in,
17 ; and tuberculosis, 39, 232 ; bacillus of, 3 ;
circulatory system in, 16 ; complications of,
27 ; diagnosis of, 30 ; diarrhoea in, 20 ; di-
gestive system in, 19; EJirlicWs reaction in,
26 ; etiology of, 2 ; grave form of, 28 ; haem-
orrhage in, 8 ; historical note on, 1 ; in the
aged, 29 ; in children, 29 ; liver in, 23 ; me-
teorism in, 22 ; mild form, 28 ; modes of con-
veyance of, 4 ; morbid anatomy of, 5 ; nerv-
ous system in, 24 ; osseous system in, 27 ;
parotitis in, 20 ; perforation of bowel in, 7,
22 ; post-typhoid elevations of temperature
in, 13 ; prognosis of, 31 ; prophylaxis of, 32 ;
relapses in, 29 ; renal system in, 25 ; respira-
tory system in, 23 ; skin rashes in, 15; spleen
in, 23 ; symptoms of, 10 ; treatment of, 33 ;
varieties of, 27.
Typho-malarial fever, so-called, 27, 152.
Typhotoxin, 3.
Typhus fever, 39 ; complications and sequelae
of, 42 ; contagiousness of, 40 ; diagnosis of,
42 ; etiology of, 39 ; morbid anatomy of, 40
period of incubation of, 40; prognosis of, 42
stage of cniption in, 41 ; symptoms of, 40
treatment of, 43.
Typhus siderans, 42.
Tyrosin, 427.
Tyrotoxicon, 1014.
Ulcer, cancerous, of intestine, 398; gastric,
368 ; of duodenum, 308 ; of bowel in dys-
entery, 132, 135; in typhoid fever, 7.
Ulcer of mouth, 324; in the new-born, 325 ; in
nursing women, 325 ; of palate in infants, 325.
Ulcer, peptic, 368 ; perforating, of foot, 844.
Ulcerative endocarditis, 695.
Ulnar nerve, affections of, 816.
Unconsciousness (see Coma).
Uraemia, cerebral manifestations of, 738, 740 ;
chronic, 740; coma in, 739; convulsions in,
739 ; diagnosis from apoplexy, 877 ; dysp-
noea in, 739 ; headache in, 739 ; in Bright's
disease, 757 ; local palsies in, 739 ; oedema of
brain in, 870 ; stomatitis in, 740 ; symptoms
of, 738 ; theory of, 737.
Urate (lithate) of soda in gout, 288.
Urates in the urine, 732.
Urates (lithates), amorphous, 732.
Ureter, mucous cysts of, 1023; obstructed by
calculi, 767 ; psorospermiasis of, 1023.
Urethritis, gouty, 293.
Uric acid, calculus, 765 ; deposition of, 732 ;
mode of elimination, 731 ; place and mode
of formation, 731 ; in gout, 288 ; in urine,
732 ; " showers," 293 ; solubility of, 732.
Uric-acid diathesis (see LiTHiEMiA), 733.
Uric-acid headache, 292.
Uric-acid theory of gout, 288.
Urinary calculi, 765.
Urine, anomalies of the secretion of, 722.
Urine, density of, in acute Bright's disease,
742 ; in chronic Bright's disease, 752 ; in
diabetes, 298 ; in diabetes insipidus, 306.
Urine, haemoglobin in, 723; in acute yellow
atrophy of liver, 427 ; in grave anaemia, 694 ;
in cholera, 122; in diabetes insipidus, 306 ;
in diabetes mellitus, 298 ; in diphtheria, 106 ;
in erysipelas, 113 ; in gout, 290, 292 ; in
jaundice, 424 ; in melanotic sarcoma, 736 ; in
pneumonia, 521 ; in acute pulmonary tuber-
culosis, 230 ; in typhoid fever, 26 ; oxalates
in, 733 ; pus in, 729.
Urine, quantity of, in chronic Bright's disease,
752; in diabetes insipidus, 306 ; in diabetes
mellitus, 298; in intestinal obstruction, 417.
Urine, retention of. In typhoid fever, 25.
Urine, suppression of, in cholera, 122; in acute
nephritis, 742 ; in scarlet fever, 72; in acute
intestinal obstruction, 417 ; obstructive sup-
pression, 767.
Urine, tests for albumen in, 727 ; biliary pig-
ment in, 424 ; blood in, 723.
Urobilin, increase of, in pernicious anaemia, 694.
Uro-genital tuberculosis, 243.
Urticaria, after tapping of hydatid cysts, 1044;
epidemioa, 1050; giant form (see Neurotic
(Edema), 990 ; with purpura, 317 ; in small-
pox, 50 ; in typhoid fever, 16.
Uterus, tuberculosis of, 245.
Uvula, oedema of, 330; infarction of, 318, 330.
Vaccination, 46 ; mark, 60 ; operation of, 64 ;
rashes, 63 ; ulcei-s, 62 ; value of, 64.
INDEX.
1079
Vaccine lymph, choice of, 63 ; from the calf,
G4; hmuanizecl, G3.
Vaccinia, GO ; generalized, Gl.
Vaccino-syphilis, G2; diagnosis from vaccina-
tion ulcers, 62.
Vagabond's discoloration, 710.
Vaginitis, gonorrhoeal, of the new-born, 276.
Valvular disease of heart, 602; prognosis in,
621 ; treatment of, 623.
Varicella, 65; hoemorrhagic, 66.
Varices, oesophageal, in cirrhosis of liver, 340.
Variola, 46 ; haemorrhagica, 52, 54 ; vera, 49.
Variola sine eruptione, 54.
Varioloid, 54.
Vaso-motor disorders, 987.
Va^o-motor disturbances, in anaemia, 687 ; in
caries, 852 ; in chronic pleurisy, 573 ; in ex-
ophthalmic goitre, 714 ; in hemicrania, 958 ;
in myelitis, 829 ; in neuralgia, 960.
Veins, cerebral, thrombosis in, 885 ; diastolic
collapse of, 590 ; pulsation in, 228, 936, 980.
Vena cava, inferior, twist in, 560.
Vena cava, superior, perforation of by aneu-
rism, 672, 682.
Venesection (see Bloodletting).
Venous pulse, 228, 936, 980.
Ventricles of brain, dilatation of (hydrocepha-
lus), 924 ; puncture of, 924.
Ventricular hoemoiThage, 872.
Verruca necrogenica, 189.
Vertebrae, caries of, 851.
Vertebral artery, obstruction of, 880.
Vertigo, auditory, 803 ; cerebellar, 921 ; in
brain tumor, 919 ; gastric, 354 ; labyrinthine,
803 ; paralyzing, 804.
Vesiculie seminales, tuberculosis of, 245.
Vicarious, epistaxis, 479 ; haemoptysis, 507.
Vitiligoidea, 424.
Vocal fremitus, 519, 561 ; resonance, 520, 562.
Voice (see Speech).
Voice, alteration of, in mouth-breathers, 337.
Volitional tremor, 913.
Volvulus, 415, 419.
Vomica, signs of, in phthisis, 216.
Vomit, black, 127 ; coffee-ground, 379.
Vomiting, in Addison's disease, 710; in
BrUjhVs disease, 754 ; from cerebral abscess,
904; from cerebral tumor, 919; in chronic
obstruction of intestines, 417; in chronic
ulcerative phthisis, 229; gall-stone colic,
432; in gastric cancer, 379; in gastric ulcer,
371 ; in acute obstruction of intestines, 416 ;
in tuberculous meningitis, 202 ; in migraine,
958 ; in peritonitis, 463 ; in small-pox, 40 ;
nervous, 361; primary periodic, 362; sterco-
raceous, 416; uraemic, 740.
Wallerian degeneration, 893.
Wall-paper, poisoning by arsenic in, 1011.
War of rebellion, statistics of dysentery in, 130.
War of rebellion, malignant measles in, 79.
Wart-pox, 52.
Warts, post-mortem, 189.
Washing out stomach, 357, 366.
Water-hammer pulse, 606.
Water, infection by, in diphtheria, 99; in
cholera, 119 ; in typhoid fever, 4.
" Water on the brain," 201.
WeiVs disease, 265.
Werlhqf^s disease (see Purpura), 318.
Wer7iicke''s liemiopic pupillary inaction, 789.
Wet-pack, 75.
Whip- worm, 1035.
White flux of India, 395.
White softening of brain, 879.
White thrombi in heart, 615.
Whooping-cough, 84; complications and se-
quelae of, 86 ; diagnosis of, 86 ; etiology of,
84; morbid anatomy of, 84; prognosis of,
86 ; symptoms of, 85 ; treatment of, 87.
Winders disease (see Epidemic Hemoglo-
binuria OF THE New-born), 171, 724.
" Wind " in the process of training, 635.
" Winged scapulte," 225.
Wintrich^s sign, 227.
Woillez, maladie de^ 503.
Wool-sorter's disease, 158.
Word-blindness, 899.
Word-deafness, 899.
Wormian bones in hydrocephalus, 923.
Worms (see Parasites).
Wrist-drop, 816 ; in lead-poisoning, 1009.
Writer's cramp, 963.
Wryneck, 810.
Wurzburg Surgical Clinic, statistics of tuber-
culosis at, 194.
Xanthelasma, 424.
Xanthine, 766.
Xanthopsia, 1026.
Xerostomia, 328.
Yellow fever, 125; diagnosis of, 128; etiology
of, 125 ; morbid anatomy of, 126 ; prognosii*
of, 128; prophylaxis of, 128; symptoms of,
127 ; treatment of, 129.
Yellow softening of brain, 879.
Yellow vision, 1026.
Yea's dietary in obesity, 1020.
Zona, 961.
Zymogen, tests for, in gastric juice, 347.
THE END.
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